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LATERAL CURVATURE OF THE SPINE 

AND 

ROUND SHOULDERS 



LOVETT 



LATERAL CURVATURE OF 
THE SPINE 

AND 

ROUND SHOULDERS 



BY 

ROBERT W. LOVETT, M. D. 

BOSTON 

JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPEDIC SURGERY, HARVARD MEDICAL 

SCHOOL; SURGEON TO THE CHILDREN'S HOSPITAL, BOSTON; SURGEON-IN-CHIEF TO THE 

MASSACHUSETTS HOSPITAL SCHOOL, CANTON; CONSULTING ORTHOPEDIC SURGEON TO 

THE BOSTON DISPENSARY; MEMBER OF THE AMERICAN ORTHOPEDIC ASSOCIATION; 

CORRESPONDING MEMBER OB THE ROYAL SOCIETY OF PHYSICIANS, BUDAPEST; 

KORRESPONDIERENDES MITGLIED DER DEUTSCHEN GESELLSCHAFT FUR 

ORTHOPADISCHE CHIRURGIE, SOCIO DELLA SOCIETA ITALIANA DI 

ORTOPEDIA 



THIRD EDITION, REVISED AND ENLARGED 
WITH 180 ILLUSTRATIONS 



PHILADELPHIA 
P. BLAKISTON'S SON & CO 

1012 WALNUT STREET 



in 



Copyright, 1916, by P. Blakiston's Son & Co. 



THE MAPLE PRESS XORK PA 



MAY I7I9I6 

©CI.A433028 



TO 

ROBERT JONES 

LIVERPOOL 

A GREAT SURGEON AND AN OLD FRIEND 



PREFACE TO THE THIRD EDITION 



In the three years and a half since the second edition of this book 
was published there has been much discussion of the question of the 
treatment of scoliosis by forcible correction, and a greatly increased 
interest has been awakened in the matter. In 191 1 a modification 
of former methods of forcible correction w r as advocated, and for this 
modification was claimed a degree of effectiveness hitherto quite 
unknown and not in accord with our pathological knowledge. 
The method thus advocated was enthusiastically accepted and 
loudly acclaimed by many competent men. But in the last year 
or two a reaction has set in, and much unfavorable criticism of the 
method has been published. Under these circumstances I have 
fallen back on my own personal experience, and have published 
certain well-recorded cases showing what I have personally been able 
to accomplish by forcible correction. In addition to this I have 
stated what I believe to be the status of the matter at present, a 
status still unsettled. Apparently the time has come when a serious 
analysis of the results by means of roentgenograms will be required 
to place the matter on a convincing basis. Assertions and opinions 
have too long prevailed in scoliosis, and tangible facts are now re- 
quired. I have rewritten a large part of the section on treatment, 
and I have revised extensively other parts of the book, condensing 
where I could and expanding where it seemed necessary. A chapter 
on the history of scoliosis has been added, because there seemed to be 
nothing in English on the subject. I have endeavored to reclassify 
and rearrange certain parts of the book in order to present with 
greater clearness certain phases of this complicated affection, because 
consideration of the matter has in the past tended toward complexity, 
and it has seemed to me that a clear statement of essential points 
was desirable in a book intended largely for use as a text-book. 

Robert W. Lovett. 



PREFACE TO FIRST EDITION 



The successful treatment of lateral curvature of the spine cannot in 
the past be counted as one of the achievements of orthopedic surgery. 
The affection is not only intrinsically resistant to treatment, but the 
therapeutic measures employed have been on the whole largely 
empirical and have not been sufficiently correlated to its pathology 
and to the mechanism by which it is caused. In the last ten years, 
however, a good deal of progress has been made along new and prom- 
ising lines, by means of experimental and clinical work, the records 
of which lie scattered through later medical literature. In the follow- 
ing pages I have attempted to bring together this literature and to 
add my own personal views and experience, in the hope of presenting 
the subject in English in a modern light and to call attention to the 
prospect offered of obtaining better results. That such a book is 
needed I have been led to infer from many inquiries in connection 
with this subject by physicians, medical students, and teachers of 
physical training. If I have devoted too large a part of the book to 
the question of treatment it is because of the scant attention paid to 
that part of the subject in most books dealing with deformities. 

The anatomical part of the work is from the Anatomical Depart- 
ment of Harvard University, and much of the clinical work is from 
the Scoliosis Clinic of the Children's Hospital, Boston. 

It is impossible to acknowledge my indebtedness individually to 
those of my colleagues and others who have helped me by contribut- 
ing material and other assistance. I should, however, express my 
obligation to Professor Thomas D wight for his advice given in con- 
nection with the anatomical part of my work, for the liberal supply 
of anatomical material with which he has provided me, and for 
criticising my chapter on Anatomy. To Miss Amy Morris Homans, 
Director of the Boston Normal School of Gymnastics, I wish to ex- 
press my indebtedness for assistance given in many ways; and to my 
assistants, Fraulein Helene Seltmann and Miss W. G. Wright, for 
great help in preparing the list of exercises. 

I have used freely the chapters on Pathology and Occurrence in the 
admirable article on Scoliosis by Schulthess of Zurich, recently pub- 
lished in JoachimsthaFs "Handbuch der Orthopadischen Chirurgie." 

Robert W. Lovett. 
Boston. 



TABLE OF CONTENTS 



Chapter Page 

I. History of Scoliosis i 

II V The Anatomy of the Vertebral Column and the 

Thorax 8 

III. The Movements of the Spine 29 

IV. The Mechanism of Scoliosis 43 

V. Description and Symptoms 51 

VI. Examination and Record of Scoliosis 71 

VII. Pathology 83 

VIII. Etiology 97 

IX. Occurrence in 

X. Relation of Scoliosis to School Life 117 

XL Diagnosis 124 

XII. Prognosis 127 

XIII. Treatment 129 

XIV. Faulty Attitude 191 

Index 211 



XI 



LATERAL CURVATURE OF THE SPINE 
AND ROUND SHOULDERS 



CHAPTER I 
THE HISTORY OF SCOLIOSIS 1 

To write the history of scoliosis one must start with the begin- 
nings of medicine and follow down through some 2500 years the 
course of an affection for many centuries classed with other cur- 
vatures of the spine, and considered, as they were considered, 
due to dislocation of the vertebrae. One finds in this, as in most 
affections long recognized, that time brings about its identification 
as an entity, after which it gradually becomes separated from 
similar affections and is discussed by itself. 

The term "scoliosis" dates much farther back than the recogni- 
tion of the affection itself. c/coXtoco, from which scoliosis is derived, 
is a Homeric word meaning to bend or twist, and the term o-koXi'cosis 
was first used by Hippocrates, who lived four centuries before the 
beginning of the Christian era. His use of the word apparently was 
to designate a lateral form of the spinal curve supposed to be due to 
dislocation, the forward curve being called lordosis and the back- 
ward curve kyphosis. There were two other words in use at this 
time which have dropped out, and which are of no significance. 

Although the name scoliosis was given by Hippocrates, a very 
short extract from his works will show that he had little or no idea of 
what the condition was. After a description of posterior curvature 
of the spine, which is fairly accurate in a very rough way, he goes 
on: — "In some cases the curvature of the spine is lateral, that is to 
say, either to the one side or to the other, and most of such cases are 
connected with tubercles (abscesses?) within the spine, and in some 
the position in which they had been accustomed to lie cooperates 

with the disease but these will be treated 

of among the common affections of the lungs." 

1 u Geschicte und Behandlung der seitlichen Ruckgratsverkriimmung," 
Strassburg, 1885. 

Chlumsky: " Prispezky k Dejinam Skoliosy," Prag, 1910 



2 THE HISTORY OF SCOLIOSIS 

" Lateral curvatures also occur, the approximate cause of which 
is the attitudes in which these people lie. These cases have the 
prognostics accordingly." 

Yet Hippocrates gave a very clear description of club-foot, which 
was well recognized by him, and although the splints advised seem 
rather inefficient, the treatment by moulding and retention was 
advocated. Patients with spinal curves, however, were tied by 
the legs to a ladder, and the ladder raised and then dropped to the 
ground, striking on one end, thus tending to straighten the spine, or 
such patients were put into an apparatus to make extension and 
pressure on the prominence. He adds as a further refinement of his 
treatment: — "It is also safe for a person to sit upon the hump while 
extension is being made, and raising himself to let himself fall down 
again upon the patient." He also suggests putting one foot on the 
hump or using a long wooden lever, but one finds no mention of any 
attempt at retention, and the reason for this is that all the treat- 
ment was based on the supposition that the affection was due to a 
dislocation, which demanded reduction only. 

For about 2000 years after Hippocrates, scoliosis attracted little 
attention and no advance was made. Paul of Aegina, 650 A. D., 
suggested bandaging to wooden strips in cases of curvature of all 
varieties, and Albukasis 500 years later announced that "no one 
could cure curvature to the side." 

And so one comes down through the centuries with no new light 
to the time of Ambroise Pare, born in 15 10, and we find him where 
we left Hippocrates 2000 years before. I quote from his writings: 
" A dislocated vertebra standing forth and making a bunch is termed 
in Greek kyphosis, but when it is depressed it is called lordosis, but 
when the same is luxated to the right or left side it maketh a scoliosis, 
which, wresting the spine, draws it into the similitude of the letter S 

Fluid and soft bodies, such as children, are very subject 

to generate this internal cause of denuxion. Thus nurses, while they 
too straitly lace the breasts and sides of girls so to make them 
slender, cause the breast-bone to cast itself in forward or back, or 
else the one shoulder to be bigger or fuller, the other more spare or 
lean. The same error is committed if they lay children frequently 
and long upon their sides, then upon their backs, or if in taking them 
up when they walk they take them only by the feet or legs and never 
put their other hand in their backs, never so much as thinking that 
children grow most toward their heads." Then follows a fair ac- 
count of the deformity, and the reduction of the dislocation is on the 



HISTOKN 3 

same lines as advocated by Hippocrates, by extension and pressure 
by the hand or by lever. He suggested, however, the use of a padded 
iron corset, the illustrations of which are familiar, but still it was 
always a dislocation that was considered. It was to be treated by 
levers and great force, and the after-treatment played only a very 
small part. 

Among the various authors of the next hundred years one finds 
silence on the subject in most, such as Fabricius, Hieronymus and 
Vesalius, but here and there are flashes of light, mostly fantastic 
speculations as to etiology, but the affection was frequent, for 
Riolan, in 1641, stated that in France the girls carried as a rule the 
left shoulder higher than the right, and that one could hardly find 
a case where the shoulders were rightly constructed. His speculations 
as to etiology were much the same as those of the nineteenth century, 
namely, the use of the right arm and the wearing of stiffened corsets. 
The first autopsy of a scoliotic case was reported in 1646 by Fabricius 
Hildanus, without apparently clearing up the matter. Glisson, 
writing of rickets, which he named rachitis, in 1660, described the 
spinal curves due to it, and suggested for this indiscriminate treat- 
ment gymnastics or suspension, but Glisson's suspension was from 
axillae, head and hands, by which the children were slung and allowed 
to play in the air, which he adds "they did with great enjoyment." 
The head sling proper dates from Nuckius in 1696, and was devised 
for the treatment of wry neck. 

From this time until the time of Andre in 1741, one cannot see 
that any author contributed much to progress, although it is evident 
that whalebone corsets were coming into use as a method of treat- 
ment, originating with Jungken in 1691, and the mention of scoliosis 
is more frequent than in the preceding century, but never apparently 
differentiated clearly from other curvatures. 

Andre was a man of originality, the inventor of the term "ortho- 
pedic," and he wrote more fully of spinal curves than his predecessors. 
He condemned high heels and blamed them and bad sitting positions 
for much of the faulty attitude. Among causes for spinal curves he 
mentioned hemorrhoids, which were so painful that the child could 
not sit squarely, and he called attention to the important fact that 
as a child grew the clothes must be made larger. He suggested 
gymnastics and apparatus as a means of treatment. 

Taking it altogether the middle of the eighteenth century, that is 
to say, the time of the beginning of the American Revolution, was a 
time of considerable activity and some little progress in the history 



4 THE HISTORY OF SCOLIOSIS 

of scoliosis. Andre was the first to group deformities together and 
to give a name to the specialty. His directions about treatment were 
vague, but he recognized in bow legs at least that the same means 
must be taken to straighten them as were adopted to straighten the 
crooked stem of a young tree. He advocated friction of the de- 
formed parts and their gradual restoration by manual extension, 
pressure and localized movement. A very distinct step at about this 
time was made by the classical work of Percival Pott, who published 
in 1779, his essay on "The Palsy of the Lower Limbs in Consequence 
of a Curvature of the Spine." In this work he took out of the un- 
classified group of affections known as curvatures of the spine, those 
posterior curves caused by spinal tuberculosis. He stated with 
regard to the paralysis "that none of those strange twists and de- 
viations which the majority of European women get in their shapes 
from the very absurd custom of dressing them in stays during their 
infancy, and which put them into all directions but the right, ever 
caused anything of this kind, however great the deformity might 
be." His description of spinal tuberculosis was so accurate that it 
immediately identified posterior curvature as a carious or scrofulous 
disease of bone and not as a dislocation, and thus cleared the field 
for the recognition of scoliosis as an entity. 

About this time scoliosis was becoming more clearly defined. 
Autopsies were being performed, and it was being recognized that it 
was not to be classed and treated with the posterior curvatures. 
This came not only from the work of Pott, but was gradually coming 
in from all sides, and apparatus of various kinds began to be devised. 
The iron cross of Heister, invented in 1700, began to be displaced by 
apparatus more of the modern type, and the corset of Maguy, de- 
vised in 1762, would find a sale to-day in the instrument shops; but 
the greatest impetus was given by the apparatus of Levacher in 
1768, which consisted of a whalebone corset to which was affixed 
jury mast and a head sling. 

Although, the period at the middle of the eighteenth century, as 
has been said, was one of considerable activity and progress in the 
development of scoliosis, at about this time there began and lasted 
for over a hundred years, the dreariest and most confusing period 
in the history of the affection. The theorist and the apparatus in- 
ventor went mad, and every form of device appeared. Braces and 
corsets infinitely complicated, worse than useless, appeared by the 
dozen. Beds especially constructed, chairs, slings, swathes, belts, 
levers and the like, all found their advocates, and theories as to the 



HISTORY 5 

causation also ran riot, but on the whole the invention and elbaora- 
tion of apparatus held the center of the stage, and one heard but 
little oi gymnastics. 

It is difficult to trace the origin of the gymnastic treatment of 
scoliosis, for it had existed from an early time. Even as early as 
Glisson a system of gymnastics was clearly formulated, and appar- 
ent ly gymnastic treatment was not at that time by any means 
new. Sydenham, 1624-1689, wrote "If anyone knew of the values 
of friction and exercise and could keep his knowledge secret he 
might easily make a fortune/' and "Fuller's Medicina Gymnastica," 
published in 1704, was followed by a similar work by Tissot in 1781, 
and by Jahn and others, who worked with energy to spread German 
gymnastics. A very decided impetus came from Sweden from Henry 
Ling, who died in 1839, and who founded a system of gymnastics 
known as the Ling system or Swedish movement treatment. An 
institute under the supervision of the Swedish government was 
established in Stockholm, and Ling was its first president. A paper 
advocating gymnastic treatment was published by Langgard in 
1868, and books and monographs followed in rapid succession. 

Thus toward the middle of the nineteenth century, at the close 
of the hundred-year period which has been spoken of as dreary and 
demoralizing, gymnastic treatment began to crowd apparatus treat- 
ment and to absorb some of the attention previously given wholly 
to mechanical treatment. From this point gymnastic treatment 
has increased in prominence until it is fair to say that to-day it 
constitutes the bulk of the scoliosis treatment in America. 

Shortly after the middle of the nineteenth century there began 
what seems to be the first real progress that had been made in 
the treatment of structural scoliosis. To one who reads the history 
of the past the impression is left that up to this time the etiology 
had been the subject of a great deal of loose and irrational theory, 
that the recognition and identification of the affection had been 
delayed for centuries, and that all treatment up to this time had 
been, as we see it to-day, ineffectual and comparatively useless. 

In 1878, Lewis A. Sayre published a book on "Spinal Disease 
and Spinal Curvature," in which he advocated their treatment 
by self-suspension and a plaster-of-Paris jacket. Self-suspension 
he credited to Dr. Benjamin Lee of Philadelphia and Prof. Mitchell 
of Philadelphia. He advocated the application of a plaster-of- 
Paris jacket in suspension, with the heels lifted from the ground, and 
he claimed for them nothing more than support in an improved posi- 



THE HISTORY OF SCOLIOSIS 

tion. The jackets were removable, and exercises were done daily. 
The treatment was too mild to be effective, but it contained appar- 
ently the germ of the modern progress in the treatment of the affec- 
tion. The use of plaster-of-Paris jackets thus became more or less 
common in cases of Pott's disease as well as of scoliosis, and the work 
of Calot in 1896, who advocated at that time the use of forcible cor- 
rection in the treatment of Pott's disease, suggested the use of more 
force than had been previously used in the correction of lateral 
curvature. Schanz published, in 1900, an account of an efficient 
technic for the application of jackets in suspension, and reported 
results in 1902. In 1901, the author reported results and described 
a technic where the patient lay on the face during the application, 
and there were other papers written at about this time, but the 
great impetus to the treatment by forcible correction came from 
Wullstein, who read a paper at the International Congress in Paris 
in 1900, and who published his experiments, methods and results 
in 1902. He showed experimentally that bony scoliosis could be 
produced in young dogs who were kept for some months in a bandage, 
inducing a lateral curve of the spine, and by the use of plaster-of- 
Paris jackets applied to the scoliotic patient in an improved position, 
induced by the use of great traction and lateral pressure, he secured 
results that were better than any previously reported. The work 
attracted much attention, and markedly modified the whole point of 
view with regard to forcible correction, which .began to gather a body 
of adherents whose number has steadily increased. 

The method of Wullstein has been extensively modified. Jackets 
have been applied with the patient on the face, on the side, on the 
back, with the spine flexed, with the spine hyperextended, on simple 
hammocks, and in complicated apparatus, but the principle demon- 
strated as effective by Wullstein and carefully elaborated by him 
has not been modified, namely, crowding the spine into an im- 
proved position and holding it there during as long a period as seems 
practicable, and for this purpose using plaster-of-Paris. 

There have been from time to time pieces of work elaborated 
which have modified our point of view with regard to the etiology 
of scoliosis, and have to a certain extent influenced our treatment. 
The work of Bohm in 1906, called our attention to the frequency 
of .congenital malformations as a cause of scoliosis, and immediately 
transferred many cases from the class of acquired to the class of 
congenital scoliosis. Subsequent work by Bohm and by others has 
laid stress on the fact that the occurrence of severe scoliosis is prob- 



HISTORY 7 

ably due to congenital conditions or to abnormalities of bone, and 
that too much importance must not be allowed to the former ideas 
that severe scoliosis was caused by assumed bad posture, carrying 
burdens, bad school positions, etc. 

The discussion in the German Orthopedic Congress in 1910, 
with regard to school life as a cause of severe scoliosis was most 
illuminating, and the majority of the writers who participated were 
of the opinion that although the school might cause a postural 
scoliosis it was very doubtful if it could be accepted as a routine 
cause of severe scoliosis. 

The monumental work of Schultess in the Joachimsthal Hand- 
buch fur Orthopadische Chirurgie formulated, clarified and illustrated 
our knowledge of scoliosis. 

What the prevailing treatment of scoliosis is to-day cannot be 
stated in a few sentences. Some men advocate one method, some 
another. To those of us who believe that forcible correction has ac- 
complished more than any other treatment and will accomplish more 
in the future, the development of the real treatment of scoliosis 
dates from 1875. To those who believe that the gymnastic treat- 
ment of scoliosis is the best, and that forcible correction is wrong, the 
progress in the matter of scoliosis starts with Hippocrates and comes 
down in a wavering and discouraging line from that date until the 
present, with a better knowledge of the affection on the whole, with 
probably some more effective gymnastic technic, but without any 
very great advance within the last hundred years in the line of 
efficiency. 



CHAPTER II 

ANATOMY OF THE VERTEBRAL COLUMN AND THE 

THORAX 

The spine is a flexible weight-bearing column made up of a series 
of vertebrae separated from each other by twenty-three intervertebral 
discs and connected with each other by ligaments and muscles. In 
early life the vertebras are thirty-three in number. The upper 
twenty-four, remaining separate throughout life, are distinguished as 
true, movable, or presacral vertebras. In the adult the lower nine are 
fused into two masses to form the sacrum and the coccyx, and are called 
the false, fixed, or immovable vertebrae. The spine forms the central 
axis of the skeleton, situated in the median plane of the body and 
posterior part of the trunk. By the term "the spine" is generally 
understood the part of the column above the sacrum. 

In shape the spinal column is roughly pyramidal, the column of 
vertebral bodies tapering from below upward, and after early in- 
fancy it shows four curves, two anterior and two posterior, in the 
sagittal or median anteroposterior plane. These are called the 
physiological curves, which will be discussed later in the chapter. 

The spine encloses and protects the spinal cord, and provides, with 
the sacrum, thirty-one pairs of intervertebral foramina through 
which the spinal nerves emerge. It serves by its intervertebral 
discs to diminish the jar of walking. 

The total length of the spine is given as follows by different authors: 
Cunningham, 70 to 73 cm.; Morris, 70 cm.; and Krause, 72 to 75 cm. 
(along the curves), which is 45 per cent, of the body-length. The 
relative length of the separate regions is shown in the following 
table: 

Dwight 3 
Cunningham 1 Morris 2 Beaunois -, , „ , 

6 Males Females 

Cervical region 13-140111. 12.5 cm. 10.8 cm. 13.3 cm. 12.1cm. 

Dorsal region 27-29 cm. 27.5 cm. 27.0 cm. 28.7 cm. 26.5 cm. 

Lumbar region 12-15 cm. 17.5 cm. 16.8 cm. 19.9 cm. 18.7 cm. 

It is frequently stated that the length of the spine in different in- 
dividuals is pretty constant, but Dwight's figures show rather a wide 

1 Cunningham: "Text-book of Anatomy," Macmillan, 1902. 

2 Morris: "Human Anatomy," Blakiston, 1903. 
3 Dwight: "Medical Record," Sept. 8, 1894. 



AX ATOMY 9 

variation. In fifty-six male spines the longest was 69.8 cm. and the 
shortest 56.4 cm. 

In a straight line, the column measures in men from 66 to 70 cm., 
and in women from 66 to 69 cm., with an average of 67 cm. (Krause). 
This height is approximately 40 P er cent - of the total height of the 




Fig. 1. — The Spixe Seex from the 
Side, Showing the Physiological 
Curves. — (Warren Museum.) 



Fig. 2. — The Spixe Seex from the 
Froxt. — (Warren Museum.) 



individual. In the fetus and young child the column forms a greater 
proportion of the body-length. At puberty the more rapid growth 
of the rest of the body overtakes that of the spine, which completes 
its growth between the ages of twenty- three and thirty-one years. 
The percentage of total length of the individual occupied by the 



IO ANATOMY OF VERTEBRAL COLUMN AND THORAX 

spine without the sacrum is given for different ages by Moser as 
follows : 

Age Body-length Vert f e b -J h Column ^ brllfolurnlTo"' 

iengttl body-length 

o 50 192 38.4 

3 86 31.7 36.8 

5 112 35 30 

11 138 41 29.7 

14 152 44 28.9 

15K 162 45 28.1 

. Adult 167 57 34.1 

The spine is divided into three regions corresponding to the parts 
of the trunk with which it is connected: (1) The cervical region; (2) 
the thoracic or dorsal region; (3) the lumbar region. 

The cervical region comprises, the upper seven vertebrae, including 
the atlas and axis; the thoracic, twelve vertebrae; and the lumbar, 
five vertebrae. The lower part of the spine may be spoken of as the 
posterior end, while the upper part may be called the anterior end 
of the column. The middle of the spine is placed at the eleventh 
dorsal vertebra. 

INTERVERTEBRAL DISCS 

The bodies of the vertebrae, from the second cervical to the sacrum, 
are firmly held together by the intervertebral discs lying between 
them, twenty-three in number. The discs correspond in size and 
shape to the horizontal surfaces of the bodies of the vertebrae be- 
tween which they are found, but they project slightly beyond the 
edges of the vertebrae. The sum of the heights of all the discs is 
greatest through the middle portion, next largest through the anterior 
borders, and least through the posterior borders. Singly the discs 
vary in height in the different regions of the spine. They are higher 
anteriorly in the cervical and lumbar regions and posteriorly in the 
dorsal region. The ratio of the height of the discs to the height of 
the bodies varies according to different authors. Weber gives the 
ratio of the average height of all the discs to the average height of 
all the vertebrae, not including the sacrum, as 1 :$. According to 
the same author the ratio of the height of all the discs through the 
centers to the height of the vertebral column, represented by a 
perpendicular from the highest point of the atlas to the sacrum, is 
as 1:4. 

The influence of the discs in the formation of the physiological 
curves of the spine is shown by the two curves in Fig. 4. Curve (^4) 



PHYSIOLOGICAL CURVES 



II 



vmh 



is formed by the bodies and the discs together, and curve (B) is the 
result obtained by placing the bodies one upon the other, forming 
a long curve with convexity backward, greatest 
in the lower dorsal region. The convexity of 
the thoracic spine is flattened in the upper part, 
and the lumbar and cervical physiological curves 
almost completely disappear when the discs are 
removed. 

The discs become smaller and harder with 
age, shrinking to a greater extent where they 
are thickest than in the region where they are 
thin. For this reason the curve of the spine 
in old age approaches the long convexity back- 



Fig. 3. — Lines Rep- 
resenting the Sum of 
the Thickness of the 
Intervertebral 
Discs. — (Fick.) 

v, At the front bor- 
der; m, in the middle 
of the disc; h, at the 
posterior border. 



A B 

Fig. 4. — Curves of the Vertebral Column. — {Fick.) 
A, With intervertebral discs; B, without intervertebral discs. 

ward represented by curve (B), and the bowed 
back of old age is substituted for the upright at- 
titude with a lumbar forward curve which is 
largely due to the influence of intervertebral 
discs. 

The discs are very firmly attached to the 
bodies of the vertebrae, and are also attached 
to the anterior and posterior common ligaments 
of the spine. The intervertebral discs thus 
furnish a connecting structure of great strength 
between each two vertebrae, and at the same 



12 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



time furnish each what amounts to a ball-and-socket joint on ac- 
count of the incompressible fluid pulp in the center of each disc 
between each two vertebral bodies, except of course the first two 
cervical. 

LIGAMENTS OF THE SPINE 

In addition to the connection of the bodies by means of the inter- 
vertebral discs the vertebrae are bound together by ligaments which 
serve to limit movement between them and contribute stability and 
strength to the column. Ligaments are composed of white fibrous 




Fig. 5. — Median Section of a Portion of the Adult Lumbar Vertebral Column, 
The Right Half Seen from the Left. — (Fick.) ( 

tissue, the strongest tissue in the body, highly elastic, but non- 
extensible. Two of the spinal ligaments, the ligamentum nuchas 
and the subflava, form exceptions to this statement, being made up 
almost entirely of yellow fibrous tissue. 



SACRO-ILIAC ARTICULATION 



The strong joint between the sacrum and the ilium through which 
the whole body-weight is transmitted is a synchondrosis. These 
transmit the weight of the spine to the pelvis and thence to the legs. 



SACRO-ILIAC JOIN [ 



13 



They arc car-shaped articular surfaces of irregular contour, in genera] 
vertical in direction, containing some synovia] membrane and heavy 
ligamentous bands. That they permit some motion is well estab- 
lished, but this amount of motion is small. Klein 1 found that 25 
kg. of force applied to the symphysis with the sacrum fixed produced 
a rotation of the ilia on the sacrum, which on the average, measured 
by the excursion of the 
symphysis, was 3.9 mm. in man 
and 5.8 mm. in woman. 
Measured at the sacro-iliac 
joint this excursion was about 
one-sixth of this amount; that 
is, in man the average amount 
of motion in the sacro-iliac 
joint, measured at the pos- 
terior part of the joint, was 
about 0.6 mm. These joints 
are protected against much 
motion by intra- and extra- 
articular ligaments of the 
heaviest variety. In front of 
them lie the lumbosacral cord 
and sacral plexus. 

THORAX 

The thorax is a bony cage 
containing the principal organs 
of circulation and respiration. 
It is formed by the thoracic 
vertebrae, the ribs, the costal 
cartilages, and the sternum. 
The ribs, twelve on each side, 

form a double series of narrow, curved, flattened bones attached 
posteriorly to the thoracic vertebrae. They extend at first out- 
ward, and then forward, inward, and downward toward the me- 
dian line anteriorly. The seven upper ribs, called the true, sternal, 
or vertebrosternal ribs, are attached directly to the sternum by 
the costal cartilages anteriorly. The lower five ribs are called 

1 Klein: Ztschr. f. Geburt. u. Gynak., 1891, xxi. Walcher: "Verhandl. d. 
deutsch. Gesellsch. f. Gynak.", Bonn, 1891. Strasser: "Lehrbuch der Muskel 
und Gelenk Mechanik, Berlin," 1913. Dieulafe and St. Martin, C. R.: "Assn. 
d. Anat.", 14 Reunion Revues, 191 2. 




Fig. 6. — Model of the Spine Showing the 
Anatomical Relations, Especially the Dis- 
position of the Soft Parts in the Lumbar 
Region. — (Warren Museum.) 



14 ANATOMY OF VERTEBRAL COLUMN AND THORAX - 

false or asternal ribs; the eighth, ninth, and tenth are distinguished 
as vertebrochondral, as they are anteriorly indirectly united to the 
sternum by the cartilage of the rib or ribs above; the eleventh and 
twelfth are called floating ribs, as their anterior extremities are loose 
in the abdominal wall. The ribs increase in length from the first 
to the seventh or eighth, decreasing from the eighth to the twelfth. 
They are approximately parallel with the exception of the eleventh 
and twelfth, which slant somewhat more downward. 

It must be remembered that ribs are lower at their front ends than 
at their vertebral connection, so that if it is desired to rotate a vertebra 
by pressure on a rib, the rib horizontally opposite the vertebra is not 
to be chosen. It has been shown 1 in the cadaver (i) that rotation of 




Fig. 7. — Horizontal Section of Thorax at Seventh Dorsal Vertebra Showing the 
Position of the Vertebral Bodies. — (From Braun's Atlas-Corning.) 

vertebrae may be produced, when the extremities of the spine are 
fixed, by pressure upon any of the intermediate ribs; (2) that the 
vertebrae attached to the ribs on which pressure is made are the 
most affected; (3) that the rotation never equals the rib excursion; 
(4) that the most effective points for pressure or counterpressure are 
as far as possible from the midline anteriorly and posteriorly except 
on the lowest four ribs. 

STERNUM 

The sternum or breast-bone is situated in the median line of the 
trunk, completing the thoracic cage anteriorly. The sternum is a 
flat bone, and as a whole, it lies directed obliquely forward and 

1 Keene: "Amer. Jour, of Orth. Sur.," July, 1906, page 69. 



SHAPE AND BOUNDARIES OF THE THORAX 



15 



downward. It consists of three parts — the manubrium sterni, the 
gladiolus, and the ensiform cartilage or xiphoid process. 



SHAPE AND BOUNDARIES OF THE THORAX 

In shape the thorax is somewhat conical, larger behind than in 
front and compressed antero-posteriorly. The posterior wall is 
formed by the thoracic vertebrae, and by the ribs, from their heads 
to their angles, and is convex vertically and horizontally. Laterally 
the cage is formed by the shafts of the ribs; it is somewhat convex 
vertically and sharply convex from before backward. The anterior 

Fibrous ring of in- 

tervertebral fibro- 

cartilage 



Anterior radi- 
ate or stellate 
ligament 

Costo-central 
synovial sac 



Pulpy nucleus of 
intervertebral fibro- 
cartilage 




Costo-transverse synovial sac 



Posterior costo-transverse ligament 



Fig 8 —Horizontal Section through an Intervertebral Fibro-cartilage and the 
Corresponding Ribs. — {Morris's "Anatomy. ) 

surface, slightly convex and directed forward and downward, is 
formed by the sternum and the costal cartilages. The plane of the 
superior opening or inlet of the thorax is inclined forward and 
downward, showing a greater obliquity in women than in men. 
The inferior border of the thoracic cage is formed by the twelfth 
thoracic vertebra, the lower -borders of the twelfth rib, and by two 
curved lines, extending from the anterior extremities of the last rib 
to the inferior angles of the gladiolus, touching the anterior extremi- 
ties of the eleventh rib and the costal cartilages of the tenth, ninth, 
and eighth ribs. The angle formed by these lines is known as 
the subcostal angle. The inferior surface of the thorax is directed 
forward and downward. 



i6 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



MUSCLES OF THE SPINE AND THORAX 

The general grouping and arrangement of the muscles in their 
relation to the spine has an important practical bearing on scoliosis. 
The spine lies toward the back of a more or less cylindrical muscular 




Fig. o. — G. Herman Meyer. The 
Two Oblique Muscle Pulls. — (Feiss.) 
On the left the descending oblique, a, 
External intercostals; b, descending ob- 
lique or externus abdominis. On the right 
the ascending oblique muscle pull, c, 
Descending oblique or internus abdominis; 
d, internal intercostals; e, scalenus colli;/, 
cremaster. 




Fig. 10. — G. Herman Meyer. The 
Scheme of the Torso Musculature In- 
dicating the Direction of the Various 
Muscle Pulls. — (Feiss.) 

a. Posterior longitudinal muscle pull 
(sacrospinalis) ; b, anterior longitudinal 
muscle pull; c, oblique descending muscle 
pull; d, oblique ascending muscle pull; 
e, transverse muscle pull. 



tube of which the adbominal muscles form the front. Of muscles 
directly attached to the spine there are two varieties: (1) muscles 
running from one part of the spine to another part and to the head; 
(2) muscles running from the spine to the pelvis or shoulder-girdle. 
The abdominal muscles by their attachment to the thorax, which is 
comparatively rigid, have an action on the spine. By the combined 



MUSCLES 



17 



action of these three the erect position is maintained, or any variation 
from it is accomplished. 

In making a side flexion of the spine from the erect position, for 
example, no one muscle or group of muscles is alone active, but it 
implies a concerted and coordinated action of all the groups men- 




Frc 11. — G. Herman" Meyer. The 
System of the Sacrospinalis. — (Feiss.) 
a, Spinalis; b, longissimus dorsi; c, trans- 
versalis cervicis; d, trachelomastoideus; 
e, ileocostalis ; /, ascendens cervices; g, 
ileolumbalis (hinder portion of m. quad- 
ratic lumborum Auct.); h, obliquus capi- 
tis inferior; i, obliquus capitis superior; k, 
rectus capitis posterior major; /, rectus 
capitis posterior minor. 




Fig. 12. — G. Herman Meyer. An- 
terior Longitudinal Muscles of the 
Trunk. — (Feiss.) 

a, Sternocleido-mastoideus; b, rectus 
abdominis; c, pyramidalis. 



tioned, as well as of the muscles of the lower extremities, to keep the 
balance and perform the bending. The maintenance of the spine 
in the upright position by the muscles has been compared to the way 
in which a flagstaff: is held upright by stays reaching from the top of 
the staff to the ground. Although there is no one muscle running 



1 8 ANATOMY OF VERTEBRAL COLUMN AND THORAX 

from the head to the pelvis, there is a continuous set of muscles 
supplementing each other's action. For example, in the anterior 
line the sternomastoid runs from the skull to the front of the top of 
the thorax, the sternum connects the upper and lower ribs and forms 
a rigid piece, and the lower thorax is connected with the pelvis by 
the rectus abdominis muscle. In the back the continuity of muscular 
action is shown by the fact that before the top insertion of the longis- 
simus dorsi has been reached, the complexus and transversalis cervicis 
have begun. The whole conception of muscular action in its relation 
to gymnastics is simplified by remembering the continuity of the 
muscular tube from the head to the pelvis. 

The thorax represents a comparatively fixed cage inserted in a 
structure quite movable above and below it; muscles attached to the 
thorax are therefore indirectly attached to the spine. The compara- 
tive rigidity of the thoracic part of the spine is due to the fact that 
the majority of the ribs are attached posteriorly between two 
vertebrae, that they pass forward to be also attached to the sternum, 
and that the whole structure is one well calculated to prevent 
physiological side bending or extensive forward or backward motion 
in that region; the cage must therefore largely move as a whole. 

It has been pointed out that the dorsolumbar junction is a dividing 
point for important muscular origins and insertions above and below 
it, e.g., the psoas muscles originate largely below it and the trapezius 
above it, and that it forms a weak and movable part of the spine for 
this reason. More important than this is the fact that muscles 
connecting the thorax and pelvis will move the spine where the rigid 
dorsal region changes to the movable lumbar region and that a large 
number of muscles will therefore express their contraction by motion 
at the dorsolumbar junction. A similar weak and movable part 
of the spine is said to exist at the cervicodorsal junction, where 
important muscles (splenius and rhomboids) have a dividing point. 

NERVE-SUPPLY 

The spinal nerves emerge from the spinal canal through the inter- 
vertebral foramina and are distributed to the integument and muscles 
all over the body. Eight are cervical nerves (the first passing over 
the atlas), twelve dorsal, five lumbar, five sacral, and one coccygeal. 
Each nerve is formed by the union of two nerve roots, which occurs 
outside of the spinal cord and just inside of or at the intervertebral 
foramen. The anterior, motor, or efferent fibers come from the 



I Sterno-mastoid 
Trapezius 
> Diaphragm 

J \ Serratus 
J Shoulder 



Arm 



Hand 

(ulnar lowest) 




NER\"E-SUPPLY 

MOTOR SENSORY 



19 

REFLEX 



Neck and scalp 
Neck and shoulder 



Shoulder 



muse. Arm 



Hand 



Scapular 



Front of thorax 



[ Xiphoid area 



} Epigastric 



Extensors, knee 1 
Adductors 1 hip y 



Abductors 



Extensors(?) 
Flexors, knee(?) 

Muscles of leg 
moving foot 

Perinaeal and anal 
muscles 



Abdomen 
(Umbilicus 10th) 



Buttock, upper 
part 



Groin and scrotum 
(front) 

outer side 



Abdominal 



Thigh 



front 



[ inner side 
Leg ; inner side 
Buttock, lower 
part 

Back of thigh 
I 1 except in- 

foo d t I ■«»■* 

Perinaeum and anus 



Skin from coccyx 
to anus 



y Cremasteric 
j \ Knee-joint 



Gluteal 

Foot-clonus 

Plantar 



Fig. 13. — Diagram and Table showing the Approximate Relation to the Spinal 
Nerves of the Various Motor, Sensory, and Reflex Functions of the Spinal Cord. 
(Arranged by Dr. Gowers from anatomical and pathological data). — (Morris's "Anatomy.") 



20 ANATOMY OF VERTEBRAL COLUMN AND THORAX 

cells of the anterior horn of the cord; the posterior, sensory, or 
afferent fibers emerge from the cells of the posterior horn on the same 
side of the cord. The nerve formed by these two roots on leaving 
the intervertebral foramen divides into an anterior and posterior 
branch, each with motor and sensory fibers. The posterior divisions 
are small and supply the skin and muscles of the back. The anterior 
divisions are distributed to the neck, the front and sides of the trunk, 
and to the extremities. Each anterior division is connected with 
a plexus, ganglion, or nerve of the sympathetic system. 

EVOLUTION OF THE SPINE 

The history of the spine in its evolution is of interest. In the 
Clyclostomata the vertebral column consists of a non-segmented, 
homogeneous, cartilaginous rod. Articular processes first appear 
in the Rays and Teleostei. The backbone of the lower fishes con- 
sists of a series of bony discs bound together by elastic intervertebral 
discs. It would seem from the history of the spine as if articular 
processes developed concomitantly with the elaboration of struc- 
ture, and as if they were incidental to its use rather than factors 
determining of themselves its types of motion. 

As will be mentioned in a later section, the human spine, from 
an evolutionary point of view, is practically the quadruped spine 
set on end, a matter which has a distinct bearing on its weaknesses 
as an upright supporting column. 

OSSIFICATION 

The ossification of a vertebra occurs from three primary centers, 
one for the body and one for each lateral mass. These appear in the 
sixth week, and in the cervical region the lateral centers are the first 
to appear, while in the dorsal region the one for the body is the first 
seen. The center for the body is often double in appearance if not 
in reality. The centers for the lateral masses are found near the 
bases of the articular processes and from them form the pedicles, 
laminae, articular processes, and a large part of the transverse and 
spinous processes, the bodies of the vertebrae forming from the other 
center. The vertebral epiphyses serve to assist in the formation of 
joints, to provide for the attachment of ligaments and tendons, and 
to increase the development in length of the bone of which they form 
a part. At about puberty appear five other secondary or comple- 



PHYSIOLOGICAL CURVES 21 

mentary centers, one at the tip of the spinous process, one at the tip 
of each transverse process, and one at the upper and one at the lower 
surface of each body, occurring as a flat meniscus at about the seven- 
teenth year and uniting to the vertebral body a few years later 
(twentieth year). Inasmuch as vertebral growth occurs at each of 
these epiphyses, this complicated method of ossification is important 
because the injury or disease of one of these epiphyseal lines might 
lead to serious bony deformity of the vertebra (Figs. 14 and 15). 

ELASTICITY OF SPINE 

The spinal column is capable of some movement in all directions. 
The elasticity of the intervertebral discs is such that the ball-and- 
socket joint between each two vertebrae allows motion between them 
in any plane or direction until limited by bony contact and ligamen- 
tous or muscular tension. It also allows rotation to occur between 
two separate vertebrae in an approximately horizontal plane. Bone 
is slightly compressible, but this is not a factor of importance in con- 
tributing to vertebral flexibility. 

In childhood the vertebrae are largely cartilaginous, and the in- 
creasing proportion of bone, along with the diminishing proportion of 
cartilage, causes a decrease of flexibility from youth to adult age, 
aside from the fact that the flexibility of all joints is greater in youth. 
With old age the capability of movement of the spine is greatly less- 
ened on account of the atrophy of the intervertebral discs. 

PLANES OF THE BODY 

The planes of the body will be frequently spoken of and should be 
defined. The frontal plane is a vertical and transverse one. The 
sagittal or antero-posterior plane runs in the antero-posterior axis. 
The term horizontal plane is self-explanatory. 

PHYSIOLOGICAL CURVES (ANTERO-POSTERIOR) 

The physiological curves, so called, are antero-posterior curves 
and are important. They are three in number. 

The dorsal (backward) curve is the first to become evident, and 
was found present in 86 per cent, of normal children under one year 
old when lying on the face and in 99 per cent, of children over one 
year old. In children under six months this backward convexity 



22 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



included the lumbar region, but after this age it did not as a rule, 1 
the lumbar curve then occurring at the expense, of the dorsal curve. 
The lumbar (forward) curve in lying showed frequently after the 
age of one year and in a very large majority of cases after the age 
of three years. The lumbar curve when it formed took the place 
of part of the original backward dorsal curve and was more marked 



Epiphyseal plate or disc 




Mammillary tubercle 



Transverse process 



Spinous process 



Epiphyseal plate or disc 



Fig. 



14. — Lumbar Vertebra at the Eighteenth Year with Secondary Centers.- 
(Morris's "Anatomy") 



in standing than in lying. In standing it was present after the age 
of two years in a very large majority of cases, the exceptions being 
usually in children under three who had not walked. The lumbar 
curve in childhood is obliterated in the sitting position, only four chil- 
dren of those examined between the ages of nine and thirteen showing 
such a curve in the sitting position. 



Lamina 




Neuro-central suture 
Centrum 

Fig. 15. — 'Ossification of the Fifth Lumbar Vertebra. — (Morris's "Anatomy.") 

The cervical (forward) curve could not be accurately determined 
in either standing or lying in the youngest children, but after the age 
of fourteen months this curve was observed in standing. 

In the adult, the part played by the bodies of the vertebrae and the 
discs in producing the physiological curves is shown by the following 
table: 

^ovett, Davis, and Montgomery: "Arch, di Ortopedia," iqo6,^v and vi, 
page 372. 



PHYSIOLOGICAL C\ RV] S 



23 



Difference between the Sums of the Anterior and Posterior Borders 

Vertebrae Discs 

Cervical region 1.3 mm. 7 . 8 mm. 

Dorsal region 13.3 mm. 9 . 2 mm. 

Lumbar region 6.7 mm. 21 . 1 mm. 

The cervical curve is formed principally by the intervertebral discs. 
It is a fairly mobile curve, and may be straightened by suspension. 
The dorsal curve is formed chiefly by the 
bodies of the vertebrae; it is a rigid 
curve and cannot be obliterated. The 
lumbar physiological curve is produced 
mainly by the greater anterior height 
of the intervertebral discs and is there- 
fore mobile. 

A slight physiological lateral curve 
convex to the right has long been recog- 
nized in the spine. It has been attri- 
buted to the pressure of the aorta on the 
vertebral bodies, to excessive use of the 
right side of the body in certain occu- 
pations, and to right-handedness. The 
almost constant occurrence of the curve 
indicates a common cause, which is 
most probably aortic pressure. The 
asymmetry extends from the fifth dor- 
sal to the second or third lumbar ver- 
tebra. The body of the fifth dorsal ver- 
tebra is flattened on the left side, and 
the discs above and below are similarly 
affected. There is a groove from ij^ to 
2 cm. broad passing downward in a 

spiral direction, following the course of the aorta, to the anterior 
surface of the second or third lumbar vertebra. The discs between 
these vertebrae are usually less projecting than the others, and if 
the cutting away of the vertebra cannot be seen the flattening of 
the disc is always apparent. 1 

PELVIC INCLINATION 

The position of the pelvis in relation to the horizontal plane 

would be of importance in relation to scoliosis and faulty attitude if 

it could be accurately measured in the living subject. 

^ere: "Les courb. lat. norm du Rachis humaine," These de Toulouse, 
1900. 




Fig. 16. — Section- of the Spine 
of a New-born Infant. 



24 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



If the front part of the pelvis is lowered and the back part cor- 
respondingly tilted up it is spoken of as "increased inclination" of the 
pelvis. If the front part is raised and the back part lowered it- is 
spoken of as "diminished inclination." With the former is asso- 
ciated an increase of the lumbar physiological curve, and with the 
latter a flattening of it. Changes in inclination of the pelvis must 



GIRL 

I '/a YRS 

Sitting Front 



Standing 



.7™C 




GIRL 
llYRS. 



.4™L 



-4™F? 



4 TH L 




Fig. 17. — Tracings of Physiological Curves of Normal Children: on the Left of 
a Girl of One and a Half Years, on the Right of a Girl of Eleven. 



form an important element in the faulty attitude to be spoken of 
as round shoulders. 

The internal or true conjugate diameter (conjugata vera) of the 
pelvis is a line from the sacrolumbar junction to the top of the sym- 
physis pubis and is generally accepted as the line by which pelvic 
inclination is to be determined. The angle which this line makes 
with the horizon when the patient stands erect is spoken of as the 



PELVIC INCLINATION 25 

"angle of pelvic inclination," and the observers do not wholly agree 
in their results. It is probable that no measurements of pelvic 
inclination in the living subject are sufficiently accurate to be of 
value. 

In men the variation in the average of collected results is from 44 
degrees to 60 degrees, and in women from 41 degrees to 65 degrees. 
The results of Prochovnik were obtained by the most accurate 
method of any and the research was conducted entirely on living 
subjects. The variation in men, according to his figures, was from 26 
degrees to 76 degrees, and in women from 40.5 degrees to 71 degrees. 

A research by Reynolds and Lovett 1 was undertaken as to the 
mechanics of the antero-posterior position in the upright living indi- 
vidual, in which research a determination of pelvic inclination and its 
variations under varying static conditions would have been of pre- 
sumable value, but after months of experimentation with various 
methods the investigators came to the conclusion that it was impos- 
sible to measure the variations in the inclination of the pelvis in a 
living individual with sufficient accuracy to be of any practical 
value. 

The following figures are therefore quoted in the belief that they 
can only be approximate and that they must be taken only in the 
most general way. They are partly obtained from the living, but in 
many instances are from the cadaver. 

Average in Average in 

men women 

Year 1 745, ATiiller 45 degrees 

Year 1825, Nagele 2 60 " 

Year 1836, Weber Brothers 3 65 degrees 

Year 184 1, Krause 4 60 " 60 " 

Year 1873, Meyer* 55 " 50 " 

Year 1882, Prochovnik 6 .. 54-17" S 1 -! 2 " 

Year 1898, Henggeler 7 44 " 41 . 1 " 

In 1 910 Engelhard 8 published some observations on pelvic inclina- 
tion in living children from six to fourteen. The extremes of inclina- 
tion were from 21 degrees to 46 degrees to the horizontal with an 
average inclination of 32 degrees. 

1 .E Reynolds and R. W. Lovett: "Journ. Am. Med. Assn.," Mar. 26, 1910. 

2 "Das Weibl Becken," etc., Carlsruhe, 1825. 

3 "Mech. d. Menschl. Gehwerkzeuge," Gottingen, 1836. 

4 "Hdbch. d. Mensch. Anat. Hauft.," 1, 1, 324, Hanover, 1841. 

5 "Muller's Archiv," 1873, 9- 

6 "Archiv f. Gyn.," 1882, xix, 1. 

7 "Zeitsch. f. orth. Chir.," xii, 4, 613. 

8 "Zeitsch. f. orth. Chir.," xxvii, page 1, 1910. 



26 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



Seventy-six males and eighty females, all apparently normal, over 
the age of fifteen were investigated and tabulated by Prochovnik as 
follows: 

Least inclination Greatest Average 

Males 26 degrees 76 degrees 51.72 degrees 

Females 40.5 " 71 " 54. 17 " 

The grouping of the results suggests that a normal pelvis shows an 
inclination of from 50 to 60 degrees, that there is a subnormal zone 

from 45 to 50 degrees, a supra- 
normal of 60 to 65 degrees, but 
that an inclination above 65 de- 
grees or below 45 degrees is to be 
regarded as pathological. The 
figures given refer to the external 
conjugate and are a little higher 
when the internal conjugate is 
taken as determining the angle of 
inclination. 

The whole subject of pelvic in- 
clination and its variations, the 
influences of such changes of in- 
clination on static conditions, and 
the difference of inclination be- 
tween children and adults must 
therefore be left in an unsatisfactory and unsettled condition. 




Fig. 18. — Female Pelvis, Median 
Section. — (Spalteholz.) 
The solid line running up and back from 
the symphysis indicates the "external con- 
jugate diameter." 



SURFACE ANATOMY OF THE BACK 

The position of the spine in the median line of the body is indicated 
on the normal back by a longitudinal furrow (median furrow) extend- 
ing from the occipital bone to the sacrum. The lower end of the 
furrow corresponds to the interval between the fifth lumbar vertebra 
and the sacrum. In the cervical region this furrow lies between the 
trapezii and complexi, and in the dorsal and lumbar regions it lies 
between the erector spinae muscles. It is usually most marked in the 
upper lumbar and lower dorsal regions. 

Identification of Vertebra. — In this median furrow the spinous proc- 
esses of the lower cervical vertebras can be felt easily, but the spine 
of the second cervical vertebra can be reached by. deep pressure in 
a relaxed neck; in a poorly developed individual they can be seen 
in the erect position, and in one well developed in forward bending. 



SURFACE ANATOMY OF THE BACK 27 

The spinous process of the seventh cervical vertebra is usually quite 
prominent, though that of the first thoracic may be still more so. In 
proceeding downward the root of the spine of the scapula should be 
found opposite the. spinous process of the third dorsal vertebra, and 
the inferior angle of the scapula opposite that of the seventh dorsal 
vertebra. The spine of the fourth lumbar vertebra is on a level with 
the highest points of the iliac crests. The spinous process of the 
fifth lumbar vertebra is very short, and usually forms a slight de- 
pression instead of a prominence. The third sacral vertebra is on the 
line drawn between the posterior superior spines of the ilium, and this 
line lies over the sacro-iliac joints. The twelfth dorsal vertebra is 
found by counting down from the seventh dorsal and up from the 
fourth lumbar vertebra, and any vertebra may be found in this way. 
Of the methods of identification this is the most reliable. In the 
dorsal region the obliquity of the spinous processes causes the tip of 
each to be opposite the body of the vertebra next below it. So the 
spine of the second dorsal vertebra corresponds to the head of the 
third rib, but the eleventh and twelfth dorsal spines are opposite the 
heads of the eleventh and twelfth ribs. The spinous processes of 
the lumbar vertebras are opposite the lower parts of the correspond- 
ing bodies and the discs below them. 

In the adult the spinal cord ends at the lower border of the first 
lumbar vertebra; in children the cord terminates at the lower border 
of the third lumbar vertebra. 

Muscles. — The outline of the neck posteriorly is formed by the 
trapezii and underlying muscles. The surface of the shoulder is 
shaped by the deltoid and the muscles underlying the trapezius. 
The posterior border of the axilla is formed by the latissimus dorsi, 
which also takes part in forming the contour of the lower part of the 
back. In action the anterior edge of the latissimus dorsi may be seen 
as a fold extending from the crest of the ilium to the axilla. The 
erector spinae muscles form a rounded prominence longitudinally on 
either side of the spine in the lumbar region. 

The following table from Gray's "Anatomy" gives the relation of 
the spines of the vertebrae to important organs: 



28 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



Tabular Plan of Parts Opposite the Spines of the Vertebra (Gray) 



Cervical. 



Dorsal. 



5th. Cricoid cartilage. Esophagus begins. 

7th. Apex of lung: higher in the female than in the male. 

3d. Aorta reaches spine. Apex of lower lobe of lung. Angle 

of bifurcation of trachea. 
4th. Aortic arch ends. Upper level of heart. 
8th. Lower level of heart. Central tendon of diaphragm. 
9th. Esophagus and vena cava through diaphragm. Upper 

edge of spleen. 
10th. Lower edge of lung. Liver comes to surface posteriorly. 

Cardiac orifice of stomach, 
nth. Lower border of spleen. Renal capsule. 
12th. Lowest part of pleura. Aorta through diaphragm. Py- 
lorus. 
1 st. Renal arteries. Pelvis of kidney. 

2d. Termination of spinal cord. Pancreas. Duodenum just 
Lumbar.... \ below. Receptaculum chyli. 

3d. Umbilicus. Lower border of kidney. 
4th. Division of aorta. Highest part of ilium. 

Points for Lateral Corrective Pressure. — The points at which cor- 
rective side pressure may be applied to the spine are determined by 
anatomical conditions. The important structures lying on both 
sides of the spine in the cervical and lumbar regions make it impos- 
sible to use effective side pressure upon a curved spine in these re- 
gions. In the dorsal region side pressure on the ribs is effective on 
the vertebrae, but it cannot be exerted on the upper vertebras higher, 
of course, than the axilla. The anterior border of the axilla is formed 
by the pectoralis major muscle and is in the line of the fifth rib. 
This rib articulates with both the fourth and fifth dorsal vertebrae. 
Although with the arm nearly at the side the third rib may be reached 
by the exploring hand, side pressure on the thorax cannot be exerted 
efficiently above the fourth or fifth rib. 



CHAPTER III 
THE MOVEMENTS OF THE SPINE 1 

The movements of the human spine are three in number: 

(i) Flexion, (2) extension, and (3) a compound movement — side 
bending-rotation. 

The statement that there are four movements (flexion, extension, 
rotation and side bending) is wholly incorrect, as neither side bending 
nor rotation exists in a pure form as may be demonstrated on any 
normal child. The statement that such movements exist as pure 
movements necessarily leads to a false basis for gymnastic exercises 
and obscures the whole mechanism of scoliosis. 

As long ago as 1844 Henry J. Bigelow wrote: "The principle of 
torsion is illustrated by bending a flat blade of grass or a flat, flexible 
stick in the direction of its width. The center immediately rotates 
upon its longitudinal axis to bend flatwise in the direction of its thick- 
ness. In the same way the spine, laterally flexed, turns upon its 
vertical axis to yield in its shortest or antero-posterior diameter." 
Occasional references are found to the association of torsion with 
lateral flexion, but no general recognition of the relation between the 
two has existed. 

The human spine is not an extremely flexible structure taken by 
itself; much of its apparent flexibility is due to accessory movements 
between the spine and the pelvis and the head. An extreme forward 
flexion, e.g., in the living model or the intact cadaver, with the flexed 
head, the drooping shoulders, and the rotated pelvis, implies a greater 
curve than the spine itself possesses. It is surprising to see in the 
cadaver how comparatively little actual mobility is possessed by the 
three regions of the spine considered separately, or by the whole spine. 

The application of this is obvious without extended comment. 
If active or passive exercises are given which are intended to take 
effect upon the spine alone and to be effective there, the pelvis must 
be fixed. If this is not done, part of the muscular force is used in 
displacing the pelvis to the opposite side to balance the body, and 
the movement becomes a general and not a spinal one. 

1 R. W. Lovett: "Bos. Med. and Surg. Jour.," June 4, 1900, Oct. 31, 1901, 
Mar. 17, 1904, Sept. 28, 1905; c: Amer. Jour, of Anat.," ii, 4, 457. 

29 



30 



THE MOVEMENTS OF THE SPINE 



I. FLEXION (FORWARD BENDING) 

Is a pure antero-posterior movement without perceptible rotation. It is the 
most evenly distributed of the spinal movements, and in extreme flexion the out- 
line of the tips of the spinous processes forms a curve approaching the arc of a 
circle. Most of the movement is accomplished in the lumbar region, which in 
extreme flexion loses most of its forward convexity, but in adult observations 
was not observed to become convex backward. 




Fig. 19. — Flexion of the Spine in the Model. 



The dorsal region in extreme flexion becomes decidedly more convex than in 
the upright position. The twelfth dorsal vertebra takes part in flexion more as a- 
lumbar than as a dorsal vertebra, and free movement occurs below it and fairly 
free movement between the eleventh and twelfth vertebrae . 

The cervical region cannot be accurately observed or measured in the model. 
In the cadaver it dries so rapidly that no conclusions can be drawn beyond the 
statement that its forward convexity may be obliterated by forcible flexion with 
the hands. 



FLEXION 



31 



The most marked flexion of the spine may be obtained by having the model 
sit CTOSS-legged and bend forward with the chest between the knees. Extreme 
passive flexion with the model lying on the side is not so great as that obtained by 
flexion in the cross-legged position. 

In flexion the distance of the seventh cervical vertebra from the sacrum when 
measured along the spinous processes is increased over the same measurement 
taken in standing or lying. 




Fig. 20. — Hyperextension in the Model. 
The head is supported to secure steadiness. 



There seems to be no constant difference in the amount of flexion obtained in 
the standing and sitting positions, the resultant curve being practically the same. 
The chief difference between flexion in model and cadaver seems to consist in 
a greater relative participation of the dorsal region in flexion in the model. 

Measurements and tracings of the spine in the model and in children show 
the relaxed sitting position to be one of slight flexion. 

Forward flexion of the spine in scoliosis tends to straighten the curved line formed 
by the spinous processes. 



32 



THE MOVEMENTS OF THE SPINE 



II. HYPEREXTENSION (BACKWARD BENDING) 

Hyperextension is a pure antero-posterior movement of the spine without 
perceptible rotation. It is not an evenly distributed movement, but occurs 
almost wholly in the lumbar and lower two dorsal vertebrae. A tracing taken over 
the spinous processes in extreme hyperextension in outline resembles a hockey 
stick. The dorsal region is but little affected, being slightly straightened by 
hyperextension. The bending reaches to about the tenth dorsal, the upper dorsal 
region showing but little diminution in the physiological curve, the twelfth dorsal 
vertebra, and, to a certain extent, the eleventh, behaving as do the lumbar 
vertebras in hyperextension. The character of the curve obtained in marked 
hyperextension is practically the same, whether it is obtained by active or passive 

means, and whether the model lies 
on the face or on the side, or stands, 
or sits. The column of vertebral 
bodies alone shows the same char- 
acter and distribution of the move- 
ment as does the intact spine of the 
cadaver. The illustration (Fig. 21) 
shows the characteristic rigidity of 
the dorsal region to hyperextension. 
In hyperextension, the distance 
from the seventh cervical vertebra 
to the sacrum, measured over the 
spinous processes, is decreased from 
the same measurement taken in the 
erect position. 

Ilia. LATERAL FLEXION (SIDE 
BENDING) 

Lateral flexion of the spine does 
not exist as a pure movement, but 
is to be considered as one part of a 
compound movement, of which twist- 
ing or rotation forms the other part. 
In describing this side bending it must be stated that the character and distri- 
bution of the movement vary widely according to the degree of flexion or exten- 
sion of the spine when the side bending is made. In other words, there is no 
one type of spinal side bending, as there are types of flexion and extension, but 
the character and distribution of the movements are wholly dependent upon 
whether the spine is flexed, erect, or hyperextended when the side bending is 
performed. 

Side bending will first be considered alone without regard to the rotation caused 
by it, and then the rotation accompanying each kind of side bending will be 
described. 

The extent and distribution of forward and backward bending have been 
investigated in children from six to fourteen years old by Engelhard, 1 and 




Fig. 21. — Hyperextension in the Cadaver. 



1 "Zeitsch. fur orth. chir.," 1910, xxvii, p. 1. 



sim: BKMHNC 



33 



Fig, 31 shows the amount and distribution of these movements as formulated 
by him in an average individual. 

Side bending in lying on the face shows a more evenly distributed lateral 
curve than does that in the erect position. The character of the curve does not 
change essentially when the shoulders and pelvis are held and the middle of the 
trunk pushed to one side. The curve in this position of the spine is greater in the 




Fig. 22. — Side Bending to the Right in the Flexed Position of the Spine in the 

Model. 

A lateral curve convex to the left is formed and the vertebral bodies have turned to the left, 

as shown by the elevation of the left side of the back. 



upper lumbar vertebras and in the two lower dorsal than in the upper part of 
the spine. 

Rotation Accompanying Side Bending Lying on the Face. — With the cadaver 
lying flat on the face on the table no rotation in side bending was found by v. 
Meyer and in some experiments by Schluthess; it was, however, found by Benno 
Schmidt. With the cadaver lying prone on a table the conditions, of course, 
are against rotation, the thorax and shoulders being to a certain extent held against 
it by the surface of the table. No perceptible rotation is noted in slight side bend- 
ing under these conditions, but the vertebral bodies turn to the concave side in 
3 



34 



THE MOVEMENTS OF THE SPINE 



marked side bending. In the model lying flat on a table one side of the chest is 
felt to press on the table harder than the other in moderate side bending. The 
point is not of great importance, as the practical problem is that of the behavior 
of the weight-bearing spine. 

Side bending in the flexed position of the spine is a more evenly distributed 
movement in which the dorsal region participates more and the lumbar region 
less than in the erect position. The greatest deviation from a line connecting the 
two ends of the spine occurs at about the eighth dorsal vertebra in both cadaver 




Fig. 23. — Side Bending in the Upright Position of the Model. 
The movement is chiefly located at the dorsolumbar junction. 



and model. In short, side bending occurs higher in the spine in flexion than in 
any other position, the lumbar region being comparatively locked against side 
bending by the flexed position. The more marked the flexed position, the 
higher in the spine is the side bending localized. 

Rotation Accompanying Side Bending in Flexion. — In the flexed position of the 
spine, side bending is accompanied by rotation of the vertebral bodies toward 
the convexity of the lateral curve. This rotation occurs chiefly in the dorsal 
region. 



SIDE BENDING 35 

Side Bending in the Erect Position. — In the cadaver side bending is most 
marked below the tenth dorsal vertebra, and the dorsal region shares but slightly. 
The lumbar region is most affected in its upper part, but shares to some extent 
throughout. Side bending in the erect position is, therefore, largely a movement 
occurring in the neighborhood of and below the lumbar dorsal junction. It shows 
the same characteristics in the cadaver, the model, and the child, except that in 
the two last named the dorsal region takes a greater relative part than in the 
cadaver. 

Rotation Accompanying Side Bending in the Erect Position. — In this position 
side bending causes the rotation of the bodies of the vertebrae to the concave side 
of the lateral curve. This, however, occurs lower down in the spine than in the 
flexed position. The dorsal region participates less and the lumbar region more 
in the movement. 




Fig. 24. — Side Bending in the Upright Position of the Cadaver, showing the Same 
Characteristics as in the Model. 



Side Bending in the Hyperextended Position of the Spine. — With the spine 
of the cadaver, model, or child hyperextended, the side bending becomes a 
sharply limited movement, localized low down in the spine and occurring almost 
wholly below the eleventh dorsal vertebra, becoming therefore, essentially a lum- 
bar movement. The dorsal region bends as a whole upon the lumbar and rocks 
over to the side practically unchanged, being locked against side bending by the 
hyperextended position. 

Side bending, therefore, is situated highest in the flexed position, lower down 
in the erect position, and lowest in hyperextension in the model cadaver, and 
child. 

Rotation Accompanying Side Bending in the Hyperextended Position. — This is 
a sharply limited movement occurring in the lumbar region, including the 



36 



THE MOVEMENTS OF THE SPINE 



twelfth dorsal as functionally a lumbar vertebra. The thorax rocks over to the 
side unchanged, and the rotation of the bodies is to the concave side of the lateral 
curve. 

Rotation accompanying side bending is, therefore, of a different type in the 
flexed position of the spine from what it is in the erect or hyperextended position. 

Illb. ROTATION 

Rotation or twisting of the spine is to be considered as part of a compound 
movement of which side bending forms the other part. For purposes of simplicity 




Fig. 25. — Side Bexdixg to the Right ix the Hyperextexded Positiox of the Spixe 

ix the Model. 

The head is supported to secure steadiness. 



the rotation element of the movement will be considered by itself. Under or- 
dinary conditions it is essentially a movement of the dorsal and cervical regions 
in which the lumbar vertebrae take but little part except in hyperextension and 
with the use of traction. The lumbar vertebral region possesses some power of 
rotation, as has been generally observed. 



ROTATION 



37 



Rotation in the Erect Position. — Rotation is freest in the erect position and 
is situated in the cervical and dorsal regions, reaching its maximum at the top 
of the cervical column and extending down the spine to the lower dorsal region, 
where it disappears. With very forcible rotation applied to the top of the column 
in the cadaver, the first and even the second lumbar vertebra may be rotated. 
The rotation in this position is accompanied by a side bend of the rotated region 
away from the side to which the bodies of the vertebrae turn. If the rotation is 
to the right, it is accompanied by a lateral bend convex to the left and vice versa. 
In the model an active rotation to the right is accompanied by a displacement of 
the trunk to the left side and vice versa. If traction is applied to the head of the 
erect cadaver, forcible twisting of the head results in rotation of the lumbar 
vertebras, including the fourth. 




Fig. 26. — Side Bending to the Right in 
Hyperextension in the Column of Ver- 
tebral Bodies. 

The same characteristics are shown as in 
the previous figure. 



Fig. 27. — Side Bending to the Right 
in the Hyperextended Position of the 
Spine in the Cadaver. 

The movement occurs chiefly at and be- 
low the dorsolumbar junction, and the bodies 
of the vertebrae turn to the right, as shown 
by the pins. The lateral curve is convex to 
the left. 



Rotation in the Flexed Position. — Rotation in the flexed position of the 
spine occurs chiefly in the cervical and upper dorsal spine, the lower dorsal and 
lumbar region seeming locked against rotating forces by the flexed position. The 
more extreme the flexion the more markedly in cadaver, model, and child is the 
rotation restricted to the cervical and upper dorsal spine. 

Rotation in the Hyperextended Position.— In hyperextended positions 
rotation with moderate manual force occurs as a twisting of the whole thorax on 
an axis in the dorsolumbar region, the upper and middorsal regions apparently 
being locked against rotation by hyperextension. The site of rotating movement 



38 



THE MOVEMENTS OF THE SPINE 



in this position is, therefore, in the one or two vertebrae above and the one or two 
vertebrae below the dorsolumbar junction. 

Rotation, therefore, is located high in flexed positions, lower in erect positions, 
and is situated lowest and is more sharply localized, in hyperextended positions. 

Side Bends Accompanying Rotation. — A lateral deviation of the spine accom- 
panies all rotations. It is situated at the site of the rotation and is convex to the 
right when the rotation is to the left and vice versa. In the erect position rotation 
causes a marked side curve in the dorsal region. 




Fig. 28. — Rotation of the Model, Face to the Right, Causing a Dorsal Lateral 
Curve Convex to the Left and a Displacement of the Trunk to the Left. 



Reasons for Torsion. — It is obvious from these experiments that there must 
be some fundamental reason for the constant occurrence of one type of torsion 
for side bendings in flexion and the occurrence of another type in extension, as 
well as for the constant association of torsion with side bending. The vertebral 
column is a flexible rod capable of bearing great weight. It is not equally flexible 
in all directions, but it is, of course, capable of some movement in all planes, and, 
as such, should come under the control of the laws governing flexible rods in 
general. The extent of any of the movements of the spine is, of course, greatly 



TORSION 



39 



influenced by the shape of the vertebral bodies, the curves of the spine, the 
character of the articular processes, the resistance of the ligaments, and the 
relative strength of the muscles. 

From the mechanical point of view, torsion results from any motion of a 
straight flexible rod in which all the particles do not move in parallel planes. 
Consequently, if such a rod is bent in two planes at the same time, torsion must 
inevitably occur. The vertebral column is not a straight flexible rod, but one 
bent in physiological curves in the antero-posterior plane; side bending must 
therefore inevitably lead to torsion, because it means bending in two planes. 
Nor does the fact that the intervertebral discs permit motion in all directions 
affect the question, because from a mechanical point of view the vertebral column 
behaves in general as it would if it were a homogeneous, flexible rod. 




Fig. 29. — Rotation of the Spine of the 
Cadaver, Face to the Right, in the 
Flexed Position of the Spine. 

The movement is seen to be located in the 
upper part of the column by the deviation of 
the pins. 



u 



Fig. 30. — -Rotation of the Spine of the 
Cadaver, Face to the Right, in the Hy- 
perextended Position. 

The movement is seen to occur in the 
lower part of the spine by the rotation of 
the pins. 



A strip of sponge rubber, half an inch in diameter and 14 inches long, rotates 
in the same way that the vertebral column does in the same position. A lateral 
curvature, in what corresponds to the flexed position of the spine, may be pro- 
duced in the rubber strip following the same rule of rotation seen in life; that is, 
the front of the rod turns toward the convexity of the lateral curve. An artificial 
lateral curvature in the rubber strip, made in what corresponds to the extended 
position of the spine, results in a reverse rotation to that from the rotation of the 
flexed position. A piece of rattan, a piece of rubber tubing, a strip of sponge 
rubber, round or square, the backbone of a fish, or the backbone of a cat, behave 
all in the same way, and rotate in the same direction as does the human spine. 



4Q 



THE MOVEMENTS OF THE SPINE 



Articular Processes. — Although it is easy to understand that the column 
of vertebral bodies by itself might easily behave as a flexible rod, yet the articular 
processes cannot be left out of account. They must be an important factor in 
determining torsion, and they must do one of two things. Either they must fall 
in with the behavior of the flexible column of bodies and serve to carry out the 
rotation which would occur without them, or the> T must obstruct or reverse the 
rotation which would occur in the column of vertebral bodies alone. ■ Experiments 
seem to show that the articular processes merely serve to accentuate the same 

rotation that would be present if the 
column of vertebral bodies were by 
itself. 

THE CERVICAL REGION 



Flexion. — It is possible to 
straighten the anterior physiological 
curve. Much of the apparent for- 
ward flexion in the cervical region in 
life is evidently due to the motion be- 
tween the occiput and the atlas. 

Hyperextension. — The physiolog- 
ical curve can be increased to a cer- 
tain extent. 

Side Bending. — Side bending is 
uniformly distributed throughout the 
cervical region and is accompanied 
by rotation of the. bodies of the ver- 
tebra to the concavity of the lateral 
curve, as in the lumbar region. 

Rotation. — Rotation is extremely 
free between the first and second 
cervical vertebra, but for the rest of 
the region it is limited. Rotation is 
accompanied by a side bend convex 
to the side opposite to which the 
bodies of the vertebrae turn; that is, 
in a right rotation the curve is con- 
vex to the left. 




Fig. 31. — Diagram of the Spinal Move- 
ments in a Living Child. — {Engelhard.) 
The solid line shows the normal position, the 
dotted line the forward bend and the line of 
dots and dashes the hyperextended position. 



DORSAL REGION 

The dorsal region is the least mobile part of the spine as a whole. The twelfth 
dorsal vertebra from the point of view of function must be regarded as a lumbar 
vertebra and not as part of the dorsal region. 

Flexion. — The dorsal spine already convex backward can be made somewhat 
more convex by forward bending, but the extent of the movement is not great and 
by no means comparable to the same movement in the lumbar region. 

Hyperextension. — Hyperextension is a motion of very slight extent in the 
dorsal region. It consists of a diminution of the backward convexity and is most 
noticeable in the lower half of the region. 



CONCLUSIONS AS TO MOVEMENTS . 4 1 

Side Bending. — Side bending of the dorsal region is a fairly evenly distributed 
movement of slight extent, presenting an even curve which is greatest in the mid- 
dorsal region. It is freest in the erect position or lying on the face. It occurs 
less markedly in flexed positions and least in hyperextension. Side bending in 
this region is always accompanied by rotation of the bodies of the vertebrae to 
the convex side of the lateral curve. 

Rotation is the most marked of dorsal movements. It reaches its greatest 
extent in the upper dorsal vertebras and diminishes toward the lower end of the 
region. In a rotation of moderate force in the upright position it extends to and 
includes the seventh or eighth dorsal vertebra. Rotation of the dorsal region is 
less easily accomplished in flexion than in the erect position and in hyperextension 
it is much limited, while in extreme hyperextension in the cadaver the dorsal 
rotation movement seems to be obliterated. 

Rotation is accompanied always by side bending, the lateral curve being convex 
to the side away from which the bodies of the vertebrae turn. In a rotation of the 
top of the column to the left the lateral curve is to the right and vice versa. 

The practical points to be borne in mind in the study of the dorsal region are 
the facts that rotation is freer than side bending, that hyperextension is extremely 
limited, and that the region on the whole is comparatively immobile. 

LUMBAR REGION 

Flexion in the lumbar region is a movement of much freedom, but the physio- 
logical curve in the adult cadaver has not been obliterated in any case observed 
by the writer. 

Hyperextension as a general spinal movement is essentially a lumbar motion 
and in that region is an evenly distributed end. 

Side bending is a free movement in the lumbar region and forms in the erect 
position a very evenly distributed curve; it is greatest in the erect position and 
least in extreme flexion. 

The rotation accompanying side bending in the lumbar spine is always with the 
bodies turning to the concavity of the lateral curve, which is to be contrasted 
with the opposite rotation occurring in side bending in the dorsal region. 

Rotation in the lumbar region is extremely limited and is diminished by extreme 
hyperextension and is least or absent in extreme flexion. The lumbar region 
possesses marked mobility in flexion, hyperextension, and side bending, and but 
little in rotation. Side bending is more free than rotation in contradistinction 
to the relation of these two movements in the dorsal region. 



CERTAIN CONCLUSIONS AS TO THE MOVEMENTS OF THE THREE 
REGIONS OF THE SPINE 

1. In the lumbar region flexion diminishes mobility in the direction of side 
bending and rotation, and extreme flexion seems to lock the lumbar spine against 
these movements. 

2. In the dorsal region hyperextension diminishes mobility in the direction of 
side bending and rotation. Extreme hyperextension seems to lock the dorsal 
spine against these movements. 

3. In flexion of the whole spine side bending is accompanied by rotation of 



42 THE MOVEMENTS OF THE SPINE 

the vertebral bodies to the convexity of the lateral curve, the characteristic of the 
dorsal region. 

4. In the erect position and in hyperextension of the whole spine side bending 
is accompanied by rotation of the vertebral bodies to the concavity of the lateral 
curve, the characteristic of the lumbar region. 

5. The dorsal region rotates more easily than it bends to the side, whereas 
the lumbar region bends to the side more easily than it rotates. 

6. Rotation in the dorsal region is accompanied by a lateral curve, the con- 
vexity of which is opposite to the side to which the bodies of the vertebrae rotate. 

These conclusions are true of the normal spine, but they do not necessarily 
apply to a deformed scoliotic spine. The nearer a scoliotic spine approaches the 
normal, the more likely are they to apply without modification. 



CHAPTER IV 
MECHANISM OF SCOLIOSIS 

The Mechanics of the Upright Position (Balance). — The spine 
is a curved, segmented, weight-bearing rod resting in unstable 
equilibrium on the sacrum, which forms part of a bony ring balanced 
on the hip-joints. Its upright position is due to a sense of balance 
possessed by the living individual, for if the cadaver is placed in the 
upright position- it falls on account of the absence of muscular ac- 
tion. This sense of balance expresses itself in a muscular contrac- 
tion by which the living individual keeps his center of gravity over 
the center of support. It is reflex and instinctive, and the individual 
has no knowledge of it as such, any more than he has of the mechan- 
ism of breathing or swallowing. 

The living individual, therefore, keeps his spine erect, ? first, because 
he has a sense of balance, and second, because he has a muscular 
system which responds to his instinctive nervous impulses and 
carries out of itself the necessary muscular adjustment which is too 
complicated to describe or formulate. This instinctive sense of 
balance and equilibrium must be regarded as an attribute of the 
erect living individual, and must be given a place in the study of 
scoliosis. It is effective in two directions: 

i. The erect person instinctively strives to keep the head approxi- 
mately over the middle of the pelvis, that is, in the sagittal or antero- 
posterior median plane of the body. 

2. The erect person instinctively strives to keep the face to the 
front and the shoulder-girdle approximately in the same plane as 
the pelvis, i.e., in the frontal or lateral plane of the body. 

This adjustment, especially the element which seeks to keep the 
shoulder-girdle in the same plane as the pelvis while disturbances 
twisting the column below are taking place, is an important factor 
in explaining the phenomena of scoliosis, as will be seen later. 

The body is, however, not a firm mass, but consists of segments 
joined together, one segment resting upon the other, and firmly 
connected by a tube made up of muscles, fasciae, and integument. 1 
Since to maintain the erect attitude the line of gravity must pass 

1 Feiss: "Amer. Jour. Orth. Surg.," iv, i, 37. 

43 



44 



MECHANISM OF SCOLIOSIS 



through the base of support, so in all positions in which balance 
is maintained there is a constant equilibration by means of shifting 
segments. 

It is necessary at this place to introduce certain elementary points 
in mechanics which are familiar to every one. 
These points are the following: 

i. The base of support of the upright human figure consists of a 
trapezoid formed by the outer borders of the feet and lines connect- 
ing the back of the heels and 
1 
I the front of the toes. 

fjj . . •■£ 2. The center of support lies 

V ■y'ofrtoi^ perpendicularly under the cen- 

ter of gravity and in the erect 
position must always lie within 
this trapezoid. 
"*= p 3. For the purpose of study- 

^^H \ ing the mechanism by which 

any weight is borne by a solid 
body in unstable equilibrium, 
the entire weight may be re- 
garded as concentrated in the 
center of gravity, and the de- 
termination of the relation be- 
tween the center of gravity and 
the bearing points determines 
the lines of stress. 

The Defects of the Upright 
Position. — An important mat- 
ter in the mechanics of the 
spine and its appendages is that it is evolved with comparatively 
slight modifications from the quadruped spine, and, in fact, is 
hardly more than the quadruped spine set upright. In the 
quadruped the spine is a horizontal sustaining structure arched 
upward, supported at one end by two anterior limbs and at the 
other by two posterior limbs; the viscera hang directly down 
from this, being supported by ligaments and attachments at right 
angles to the supporting structure. On account of the angle of the 
ribs the thoracic cavity is helped in inspiration by gravity as the 
ribs fall into the position of thoracic expansion, but they must be 
pulled up to contract the thorax; and, finally, equilibrium is much 
more easily maintained than in the biped, because the supporting 




Fig. 32. — The Right Side of the Pelvis 
of the Cadaver is Raised and the Upper 
Part of the Spixe Falls to the Left, 
Making a Lateral Curve Convex to the 
Right. 



MKCHANISM OF SCOLIOSIS 45 

base is broad and the weight of the mass to be supported is compara- 
tively small. 

When this structure with only comparatively slight modifications 
is set on end and made to fulfil the functions of a weight-bearing 
column in a plane at right angles to that for which it is best adapted, 
certain unfavorable factors are introduced which serve as distinct 




Fig. 33. — The Right Side of the Pelvis of the Model is Raised and the Upper 
Part of the Spine is Carried to the Right, Making a Lateral Curve Convex to 
the Left. (Cf. Fig. 44.) 

limitations. The column constructed to bear weight and sustain 
strain at right angles to its long axis must now bear weight and sus- 
tain strain in its long axis. The tw r o anterior limbs, which formerly 
served as props, now hang as dead weights to be supported by the 
column. To maintain equilibrium much greater muscular effort 
is necessary to maintain functional balance in the man than in the 
quadruped. The viscera hang no longer at right angles to the sup- 



46 MECHANISM OF SCOLIOSIS 

porting structure, but in the line of its long axis. The thorax to 
expand has to raise all the ribs and work against gravity. 

But what is most important in the present connection is the fact 
that the upright position is decidedly hard to maintain, because the 
base of support is so small and the height of structure to be supported 
is relatively so great. 

This structure from a mechanical point of view consists of two 
vertical legs attached to a horizontal pelvis in the middle of which is 
set an upright column expanding into a bony cage carrying the weight 
of arms, head, and thoracic contents. All the weight comes down 
through a single column, the lumbar region of the spine, which 
column rests upon the middle of the pelvis. Such a structure is 
one necessarily susceptible. to disturbances of balance, and it will 
yield to such disturbances by assuming abnormal curves either 
lateral or antero-posterior. 

Relation of Balance to Curves.— -If the pelvis of a cadaver is raised 
on the right side and the upright spine is left free to move, the top 
of the column falls to the left and the spine is curved convex to the 
right. This is the position induced by gravity. If, on the other 
hand, the right side of the pelvis of a living model is raised v and the 
upright spine is left free to move, the top of the column remains 
upright and the spine is curved in the opposite direction, convex to 
the left. This is the position of balance overcoming the position 
induced by gravity. The sense of equilibrium has worked against 
the force of gravity and has reversed the position natural to the 
cadaver. 

Anything which causes any part of the body to be held in an 
asymmetrical position will cause a lateral deviation of some part 
of the spine, because a straight erect spine in the sagittal plane is 
possible only when the person stands on both feet or sits erect 
with the arms in similar positions and the head pointing straight 
ahead. Every step, every raising of the arm, every tilting of the 
head is accompanied by a deviation of the spine from the median 
plane of the body: in other words, by a temporary lateral curve 
which disappears as the symmetrical attitude is resumed. 

If there is a visual error that causes the head to be held obliquely; 
if there is a short leg causing the pelvis to be no longer horizontal but 
slanted; if the muscles of one side of the back are paralyzed; there 
must be a constant compensation or curve which will still enable the 
center of gravity to be held over the center of support. When such 
a curved position becomes habitual for any of the reasons given or 



PLASTICITY OF HONE 



47 



for other reasons, there exists in the adaptive character of bone a 
reason why this constantly assumed malposition should make a 
change in the shape oi the bones in a growing child and that these 
changes should become fixed. 

Plasticity of Bone. — The adaptability of bone to pressure has been 
recognized in general, and has been formulated and forms one aspect 
of what is often spoken of as Wolff's 1 law, 
which may be expressed briefly as follows: 
"Every change in the formation and function 
of the bones, or of their function alone, is 
followed by certain definite changes in their 
internal architecture and equally definite sec- 
ondary alterations of their external confor- 
mation in accordance with mathematical 
laws." 

The phenomena of lateral curvature have 
become somewhat more comprehensible since 
we have understood that bone is a plastic and 
adaptable structure, adapting itself to the 
demands on it, following in its growth the 
lines of least resistance, and in children sus- 
ceptible to great changes in shape from abnor- 





Fig. 34.— Experimental 
Scoliosis in a Rabbit 
Produced by Cutting the 
Erector Spin/e Muscles. 
—(Arndt.) 



Fig. 35. — Fifth Lumbar Vertebra 
from Experimental Scoliosis in 
Rabbit. — {Arndt.) 



mal conditions. As an instance of this may be mentioned the 

great distortion of the shape of the bones in the Chinese lady's foot 

produced by bandaging. It is not necessary to multiply them, for 

we have direct experimental proof of the case in question in the 

experiments of Wullstein and Arndt. 

1 Wolff: "Das Gesetz der Transformation der Knochen," Berlin, 1892; 
Freiberg: ''Am. Jour. Med. Sci.," Dec., 1902; "Animal Mechanics," by Sir 
Charles Bell and J. Wyman, Cambridge, 1902. 



48 MECHANISM OF SCOLIOSIS 

Wullstein 1 showed, by bandaging young dogs for months in posi- 
tions with the spine bent laterally in some and in others bent back- 
ward, that a permanent bony deformity occurred which could not be 
removed by traction in the length of the spine after death. A sec- 
tion of these columns showed wedge-shaped deformity of the verte- 
brae with a " lipping" or overgrowth of the borders of the vertebrae on 
the concave side of the curve, the trabeculae being thickened on the 
side of the bodies toward the concavity. The changes were more 
marked at the articular ends of the bones than in the middle of them. 

Arndt 2 produced similar permanent curves, characterized by bony 
deformity and marked rotation, in rabbits by extirpation of the erec- 
tor trunci muscles on one side. They showed, as in Wullstein's ex- 
periments, that the changes are greatest at the articular ends of the 
bodies, and the epiphyseal plates in the most deformed vertebrae 
clearly overlap the sides of the body. 

The point to be remembered is, that the erect position is a singu- 
larly unstable one and temporary lateral deviation of the spine occurs 
in almost every movement of the body. If such deviation becomes 
permanent for any reason, it must further be remembered that grow- 
ing bone is a plastic structure and that the spine will tend to conform 
its bony shape to the abnormal position. Here then, exists the 
mechanism for the acquiring of bony lateral curvature if sufficiently 
long continued. There are, of course, many other causes of lateral 
curvature which will be mentioned. 

TYPES OF LATERAL CURVATURE 

There are two types of malposition commonly described as lateral 
curvature or scoliosis. This is unfortunate and leads to misunder- 
standing and confusion. In one, the position is that which any 
normal spine may assume; in the second, the position is one that the 
normal spine cannot assume, a position which implies a change in 
the shape of the bones. 

It would add much to a better understanding of the subject if the 
former were called faulty attitude or some similar name, and the 
term scoliosis were reserved for the latter form. 

The first is due to the adjustment necessary to keep the balance of 
the spine in the presence of one of the disturbing causes mentioned. 
If this becomes habitual, it results in a typical attitude to be de- 
scribed as total or postural lateral curvature in the chapter on Descrip- 

i "Zeitsch. f. orth. Chir.," x, 2. 
2 "Archiv f. orth. Chir.," i, 1, 2. 



BONY ROTATION 



49 



tion ami Symptoms. This attitude may persist as such or change 
to the second form to be described next. 

The second type of lateral curva- 
ture is accompanied by a change in 
the shape of the bones and soft parts. 
It cannot be reproduced experiment- 
ally in the model, cadaver, or child, 
and is not within the physiological 
limits of the spine. It must, there- 
fore, be classed as structural or organic 
lateral curvature. The characteristic 
feature is a local backward prominence 
of the ribs or lumbar transverse proc- 
esses in the curved region, which is 
called "bony rotation." 

Bony Rotation. — The reason that 
bony rotation or twisting of the verte- 
bral bodies always accompanies or- 
ganic lateral curvature has been widely 
discussed from every point of view, and 
the question has been much compli- 
cated by the abstruse reasoning applied 
to its solution. The facts seem to be 
these: the vertebral column is a flexible 
weight-bearing rod curved in the an- 
tero-posterior plane by the physiolog- 
ical curves: in a column affected by 
lateral curvature it is now beginning 
to be curved to one side in some part of 
its length. Growing bone, it has been 
stated, is a plastic structure and will 
yield to unequal conditions of weight 
or strain. This curved part of the 
column being subject to unequal con- 
ditions of weight on the two sides 
tends to yield to the side and to 
change its structure in accordance with these unequal conditions 
of weight. 

But a plastic weight-bearing column already curved in one plane 
cannot yield in another plane (i.e., to the side) without twisting, and 
in this twist the vertebrae can turn in only one way, namely, away 




Fig. 36. — Experimental Scoli- 
osis in a Young Dog Produced 
by Bandaging in a One-sided Posi- 
tion. — (Wullstein.) 



50 MECHANISM OF SCOLIOSIS 

from the greatest weight and pressure, which is, of course, on the 
concave side of the lateral curve. If they were to turn toward the 
middle line instead of away from it they would encounter the greater 
instead of the less resistance and have to raise the whole weight of the 
parts above them. In so far as they are plastic they will be com- 
pressed where the weight is greatest or on the concave side. The 
deformity of the vertebrae is therefore due to their plasticity yielding 
to conditions of unequal strain, and turning where they must turn 
to escape. 

Double Curves. — The explanation of a double curve is more dim- 
cult. It has been observed that frequently a double organic curve 
grows out of a single functional one, the reason for which will be 
explained in the chapter on Description and Symptoms. It cannot 
be said that every case of organic double curve has first been a single 
postural one, for congenital, early rachitic, and other cases make that 
unlikely, but the mechanism is present for forming double curves 
from single ones under the influence of existing conditions. The 
occurrence of bony change in some cases and the persistence of func- 
tional curves in others can only be explained by assuming a plasticity 
of the bones in certain individuals which does not exist in the bones 
of others. 

The chain of events in the cases where a single curve changes to 
a double one is then, first, a disturbance of the symmetry of the body 
and the appearance of a functional curve; second, the persistence of 
this curve from the same causes that started it, the phenomena being 
still within the normal mechanism of the spine; third, the yielding of 
plastic vertebrae in the line of least resistance and the appearance of 
rotation on the convex side of the lateral curve; fourth, the formation 
of double curves from single ones by the normal mechanism of the 
spine originating in the sense of balance and adjustment. It seems 
that in many cases, perhaps the majority, these steps cannot be 
traced, but coincide in time. 



CHAPTER V 

DESCRIPTION AND SYMPTOMS 

SYNONYMS 

English: Scoliosis, lateral curvature of the spine, rotary lateral 
curvature of the spine. 

German: Skoliose, seitliche Riickgratsverkrummung, Kypho- 
skoliose. 

French: Scoliose, deviation laterale de la taille. 

Italian: Scoliose. 

Scoliosis, or lateral curvature of the spine, is the name applied to a 
condition in which any series of vertebral spinous processes shows a 
constant deviation from the median line of the body, a deviation 
always accompanied by an element of twisting. In certain rare cases 
the twisting may be the predominant appearance. Deviation of a 
single vertebra from the median line does not constitute scoliosis. 

Although scoliosis is generally studied and classified as a deformity 
of the spine, the laws of equilibrium of the body are such that any 
deviation of the vertebral column must disturb the whole balance of 
the body, and scoliosis is, therefore, accompanied by compensating 
lateral displacement of the pelvis and legs. In this wider sense 
scoliosis is to be regarded as a deformity of the whole body, espe- 
cially manifest in the spine. 

Lateral curvature of the spine is necessarily accompanied by a 
distortion of the symmetry of the body for which the patient or her 
parents seek advice. It is not generally recognized by the laity as a 
spinal distortion, but the patient is brought for surgical advice 
because of "a high shoulder," "a prominent hip," or "a projecting 
shoulder-blade." Very often the dressmaker is the first to recog- 
nize it because she finds that she must make the skirt longer on one 
side than on the other, or because the distance from the armhole to 
the waistband is longer on one side than on the other. 

The condition is essentially a distortion, and symptoms other than 
the deformity are rather unusual in average cases. Occasionally the 
patient complains of feeling " one-sided," but this is rare. Pain is 
generally not complained of, but in neurasthenic young women, 

5i 



$2 DESCRIPTION AND SYMPTOMS 

especially with functional curves, backache may be felt more or less 
on standing. Pain in the severer cases is caused by the descent of the 
ribs to the level of the crest of the ilium against which the lower ribs 
may rub, and severe local pain may be felt. In other severe cases, 
nerve-root pressure may result from the distortion and be referred to 
the peripheral ends of the spinal nerves. 

The shortening of the trunk and the diminished capacity and im- 
mobility of the thorax may lead to impairment of the function of 
thoracic and abdominal organs, especially in severe cases, and short- 
ness of breath is common in such cases on account of diminished 
respiratory capacity. Displacement of the heart and phthisis fre- 
quently occur in severe cases during adult life. Disturbances of 
digestion are also frequent irom displacement of the stomach and 
liver. Impairment of vigor and of the general health generally 
result in severe cases in adult life, although children with severe 
curves, as a rule, suffer less deterioration of the general condition. 

It is not uncommon for patients to go through life with curves of 
moderate degree which have given rise to little or no trouble; but 
at or after middle life, when atrophy of the intervertebral discs has 
occurred, such curves may increase and give rise to a sense of asym- 
metry or to pain in the back or at nerve terminations. It can gen- 
erally be predicted that a curve of moderate severity may be more 
troublesome in later adult life. 

TERMINOLOGY 

The terms used in describing lateral curvature must be defined. 
Curves are named right or left according to their convexities, curves 
convex to the right being called right curves, and vice versa. In addi- 
tion to the terms right or left, the curves are named also according to 
the anatomical region involved in the curves. If a deviation involves 
the whole spine, it is called a total curve; all other curves are called 
cervical, dorsal, or lumbar, according to the region involved, with 
the qualifying adjective right or left preceding the anatomical name. 
If a curve involves more than one region, it is classed as cervicodorsal 
or dorsolumbar. If two curves exist, the upper curve is spoken of 
first and the lower follows, e.g., right cervicodorsal, left dorsolumbar; 
or right dorsal, left lumbar. 

It is important that the anatomical region affected by the curve be 
designated accurately and not loosely. For this purpose the seventh 
cervical and last lumbar vertebral spines are marked on the skin and 



FUNCTIONAL SCOLIOSIS 53 

connected by a string representing the long axis of the spine. Parts 
of the spine lying to the right of this line are to be classified as right 
curves, parts to the left as left curves. Such curves must be assumed 
to begin and end where they pass under this string. For example, if 
the spine from the seventh cervical to the twelfth dorsal is to the right 
of the line and below it is to the left, it is a right-dorsal, left-lumbar 
curve. If the spine from the fourth dorsal to the third lumbar is to 
the right of the line, it is a right dorsolumbar curve. 

This, therefore, provides for a simple rule for the naming of every 
curve, insisting on the fact that the location of the upper end of the 
column has nothing to do with the naming of the curve. The upper 
end of the spine may be in the median plane or at either side of it, 
without affecting in any way the recognition and description of the 
spinal curves. 

The classification of curves into primary and secondary, or com- 
pensatory, is not of great importance, nor is it sound, as one cannot 
always say which curve was really primary. Often it is obvious that 
one curve is predominant and evidently the one to be attacked in 
treatment. In other cases this cannot be done, as the curves are of 
equal degree and importance so far as can be seen. It is, however, of 
importance to recognize the predominant curve where possible. For 
example, in a marked and predominant right dorsal curve it matters 
but little, practically, whether a slight lumbar curve exists or not; for 
purposes of treatment the case is a dorsal curve. In general, rational 
treatment must eliminate unimportant factors and deal with the 
salient ones. 

The former division of lateral curvature into stages has no rational 
basis. It is a progressive affection passing over only one sharp line, 
the transition from postural or functional curves to structural or 
organic ones. ' This classification of functional and structural will, 
therefore, be adopted here with slight emphasis on a certain puzzling 
type of cases evidently in the transitional stage from the functional 
to the structural type. 

FUNCTIONAL SCOLIOSIS (TOTAL, POSTURAL, OR FALSE 

SCOLIOSIS) 

The term " total scoliosis " is applied to cases where the spine forms 
one gradual curve to one side without compensatory curves. In 90 
per cent, of such cases the curve is to the left. According to the 
figures of Scholder and at the Children's Hospital clinic, right total 



54 



DESCRIPTION AND SYMPTOMS 



scoliosis is very rarely seen, while the left curve is very common. 
The greatest point of deviation, i.e., the apex of the curve, is generally 
found at the ninth or tenth dorsal vertebra, but it may be found in 
any part of the lower half of the dorsal or upper half of the lumbar 
region. 

In frequency of occurrence total scoliosis stands in the fourth 
place in the records of the institute of Liining and Schulthess, where 

patients came for treatment, 
forming but 15.39 P er cent - °f 
the entire number of lateral 
curvatures. As to sex, the per- 
centage shown in these cases is 
24 for males and 17 for females 
(Figs. 37 and 38). In boys the 
number of total scolioses in- 
creases steadily with age, but 
in girls a decrease is noted after 





Fig. 37. — Left Total Curve. 



Fig. 38. — Left Total Curve Bent For- 
ward, Showing Prominence of Back on 
the Right. 



the twelfth year, coinciding with an increase in the number of left 
lumbar curves. Total scoliosis is found between the ages of five 
and eighteen years, as a rule. 

The deviation at the greatest curve is not often over an inch and a 
half from the median line of the body. There is no obvious compen- 
satory curve, and the untrained eye is likely to find slight cases 
normal. There is, however, a perceptible displacement of the trunk 
to the left, especially as seen from the front, and a plumb-line sus- 
pended in the median line of the body as defined by the vertical fold 



FUNCTIONAL SCOLIOSIS 55 

between the buttocks, will detect a decided deviation of the marked 
spines from the median plane. The typical characteristics of a left 
total scoliosis are as follows: (i) A general curve convex to the left; 
(2) the left shoulder is elevated; (3) the right side of the shoulder --girdle 
is carried back and the left side forward; (4) when the patient bends 
forward the right side of the back may be slightly higher than the left. 
Any case which simulates a left total curve and in which these signs 
are not all present should be subjected to the closest examination and 
will probably be found to be transitional in character. Functional 
curves disappear on suspension or recumbency, and side flexibility 
is but little limited, bending to the left being often somewhat re- 
stricted. In cases of right curves the description is reversed. 




Fig. 39. — Left Total Curve. The Patient from which Radiogram was Taken. 

The changed relation of the shoulders to the pelvis is more evi- 
dent in children with marked lumbar physiological curves than in 
cases with round backs. 1 

The position in a typical functional total curve is merely the physio- 
logical one necessitated in every normal spine for any reason made 
convex to the left, and can be produced experimentally by putting a 
book under the right foot, which raises the right side of the pelvis and 
necessitates for balance a left convex curve of the spine. A spine 
making any bend convex to the left in the erect position will turn at 
its upper end to the right, as explained in the movements of the spine. 
The thorax and shoulders will be twisted backward on the right, and 

1 Schulthess: "Zeitsch. f. orth. Chir.," vi, 399-566, 1902. 



56 



DESCRIPTION AND SYMPTOMS 



when the patient bends forward, this twisted position of the shoulders 
may be carried over into the position of forward bending, if the case 
has been of long standing, and the right side of the back will be higher 




Fig. 40. — Radiogram of Total Curve in Patient Shown in Fig. 39- 

in this position. This "reverse rotation," "concave torsion," 
"retrotorsion," as it has been called, has been much discussed 1 and is 
1 Schulthess: "Zeitsch. f. orth. Chir.," x, page 489. 



TRANSITIONAL CURVES 



57 



an accompaniment of total scoliosis, but it is a physiological matter 
easily understood by studying the mechanics of the normal spine. 
It has been claimed that total scoliosis is really a triple-compound 

curve, 1 and that the torsion to 
the concave side is really due 
to a slight right dorsal curve; 
x-rays of such cases taken in 
the standing position show, 
however, in many cases, a grad- 
ual curve to the left without 
compensating curves (Fig. 40) ; 
in other cases apparently total 
curves in x-rays taken in this 
way seem to be transitional 
cases. 





Fig. 41. — Case of "Paradoxical Dor- 
solumbar Scoliosis" Figured by Wilbou- 
chewitch. (Compare Figs. 37~39-) 



Fig. 42. — Same Case as in Fig. 47 
Bent Forward Showing Prominence 
of Ribs on Right Side with Left 
Curve. — (Wilbouchewitch.) 



TRANSITIONAL CURVES 



In many cases which on first inspection appear to be postural more 
careful examination will show that the curve is obviously changing 
from the postural to the structural type, i.e., is beginning to show 
changes in structure. 

In such transitional cases the upper part of the spine is less curved 
than the lower, and one or more of the characteristic signs of postural 
curves are most often wanting. For example, the right shoulder may 
be elevated in a left curve, or the left side of the back may be promi- 
nent upward in forward bending, or the left shoulder may be carried 
forward. Such cases must, of course, be recognized as early struc- 
tural cases, but are so nearly postural that they may be wrongly 

1 Reiner and Werndorfl: "Verhandl. Deut. Gesel. f. orth. Chir.," 1906, page 
232. 



58 DESCRIPTION AND SYMPTOMS 

classed unless identified. It is not exceptional to notice that in a 
curve that has been clearly a typical left postural one a few months 
later the dorsal spine is straightening and even becoming slightly 
curved to the right, while the twist of the shoulder-girdle has dis- 
appeared or become reversed. 

The mechanism of this is as follows: 




Fig. 43. — Boy with Left Scoliosis Photographed from Overhead, Showing the 

Carrying Back of the Shoulder-girdle on the Right. 

The front edge of the board on the floor marks the lateral plane of the pelvis. 

Mechanism of Transitional Curves. — If total scoliosis tends to increase, it must 
do so by an increase of the existing side bend and of the existing twist, since both 
are correlated, not necessarily of both in exact proportion, but to some extent 
both factors must share in it. The shoulder-girdle will, therefore, be more twisted 
as the lateral curve increases. One, however, does not see the condition clinically 
of extreme left total curve and extreme right backward rotation of the shoulder- 
girdle except, possibly, in cicatricial, hysterical, or paralytic cases. An adjust- 
ment apparently takes place when the tendency of the total curve to increase 
passes beyond a certain point. For the explanation of this, one naturally 
looks to the instinctive tendency to equilibrium and balance spoken of as an in- 
trinsic property of the upright living spine. There must be going on at all times 
this effort to square the shoulder-girdle with the pelvis and to keep the head and 
upper spine as nearly as possible in the median line of the body. This adjust- 
ment will naturally occur where the spine offers the least resistance to it, and as 
individual vertebral columns vary, the compensatory adjustment will take 
various forms. 

Assume that a child stands and sits with a left total curve. He will, after a 



TRANSITIONAL CURVES 



59 



certain point in the deformity is reached, be continually striving instinctively and 
unconsciously to twist the upper part of his spine and his shoulder-girdle forward 
on the right and to bend the upper part of his spine convex to the right to restore 
his balance. We have seen that the dorsal spine twists more easily than it 
bends to the side. He is, therefore, more likely to twist his dorsal spine than to 
bend it to the side. He will, for this reason, twist the upper dorsal spine to the 
left, which twist, as we have seen, necessarily carries with it a dorsal lateral curve 
convex to the right. 

The tendency to correct the twist of the shoulder and upper end of the spine 
is sufficient to explain the transition of a left total curve to a right dorsal, left 
lumbar curve. Such a double curve can be reproduced experimentally in the 




Fig. 44. — The Upper End of the Spine 
of the Cadaver is Held by the Hand over 
the Middle of the Pelvis, while the 
Right Side of the Pelvis is Raised, and 
a Position Like that of the Living 
Model is Produced with a Lateral 
Curve Convex to the Left. (Cf. Fig. 33.) 



Fig. 45. — Experimental Double 
Curve (Right Dorsal, Left Lumbar) 
Produced in the Cadaver by Elevating 
the Right Side of the Pelvis and 
Twisting the Upper End of the Spine, 
Face to the Left. 



cadaver, the model, and the child by inducing a left total curve and adding a 
twist, active or passive, of the shoulder-girdle forward on the right. A right 
dorsal, left lumbar lateral curve then exists. 

Support is given to this idea by the fact that in structural right dorsal, left 
lumbar curves with bony rotation, one is likely to find in looking down upon the 
standing patient that the left side of the shoulder-girdle is seen to be carried 
backward in its relation to the pelvis and the right side forward, which, of course, 
is the reversed position to that seen in the left total curve. The same relation 
of the shoulder-girdle is to be noticed in single curves to the left which are ac- 
companied by bony rotation, the position again being the reverse of that seen in 
left total scoliosis. 



6o 



DESCRIPTION AND SYMPTOMS 



The disappearance of concave-sided torsion which has once existed in any 
part of the spine may indicate that the compensatory change has already begun 
and that the so-called total scoliosis has begun on its transition to a compound 
curve. 

We should, therefore, regard with suspicion any case of apparent total scoliosis 
that shows any departure from the clinical type described (see page 55), such cases 
probably having entered on the stage of transition. 




Fig. 46. — •Experimental Double Curve (Right Dorsal, Left Lumbar) Produced in 
the Model by Elevating the Right Side of the Pelvis and Having the Model 
Actively twist the Upper Spine, Face to the Left. 



That left total curves most frequently change to right dorsal, left 
lumbar compound curves than to any other form is shown by the 
figures of Hess and by a statement of Schulthess. 1 But we cannot 
expect the same final curve always to result from the same initial 
curve. Various forms of curves may occur from the same simple 
curve. For example, the dorsal region may not react as described, 

1 Liining and Schulthess: " Orth. Chir.," 1901, page 248. 



STRUCTURAL SCOLIOSIS 6 1 

and the dorsal and lumbar region may yield, as a whole, to the left, 
later showing bony rotation on the left side. The spine has yielded 
backward and to the left as a whole, and other types of compound 
curves may obviously result from the same initial curve. 

In his investigations concerning the persistence of total scoliosis 
Hess records the observations of 86 cases between the ages of five 
and twenty-one years during periods varying from tw r o weeks to 
eight years and a half. Of these 86 cases, 6o persisted as total sco- 
lioses, and the remaining 26 underwent various changes, as showm by 
the list given below. 

(a) Left total scoliosis in — 

7 cases changed to right dorsal, left dorsolumbar scoliosis. 

4 cases changed to left lumbar curves, with two right dorsal. 

3 cases changed to left dorsal curves. 

2 cases changed to left dorsal, right dorsolumbar curves. 

2 cases changed to right dorsal curves. 

1 case changed to left dorsal, right dorsolumbar. 

1 case changed to slight left cervicodorsal curve. 

1 case showed slight compensating curves. 



(b) Right total scoliosis in — 

1 case became right dorsal, left dorsolumbar. 

1 case became left dorsal, right dorsolumbar. 

1 case becsme left dorsal. 

1 case became right dorsal. 

1 case became left dorsal, right lumbar. 



5 cases. 



STRUCTURAL SCOLIOSIS (ORGANIC, HABITUAL OR 
TRUE SCOLIOSIS) 

This term is applied to those cases in which there is reason to 
believe that a structural change has occurred in the vertebrae, which 
is discussed in the chapter on Pathology. 

Structural curves are simple or compound — simple, when the de- 
viation is accompanied by no compensating curves, e.g., left lumbar 
scoliosis. The scoliosis is compound when more than one curve is 
present, e.g., right dorsal, left lumbar scoliosis. The simple curves 
have sometimes been spoken of as C curves and the double as 
S curves. Triple curves at times exist. When compound curves 
are present, they alternate to the right and left, two left curves, e.g., 
not separated by a right curve, never being seen. 



62 



DESCRIPTION AND SYMPTOMS 



No attempt has been made to discriminate between the words 
" torsion" and ''rotation," and they have been used interchangeably 
in the text. The German writers distinguish between the two terms 

in a highly technical way, a 
distinction which it does not 
seem desirable to transfer to 
English. 

VARIETIES OF STRUCTURAL 

SCOLIOSIS (LUMBAR 

CURVES) 

Lumbar scoliosis exists as 
a simple curve, but more often 
is only one component of a 
compound curve, the dorsal 
curve being, of course, in the 
opposite direction. In the 
Schulthess figures the simple 
lumbar curve formed 11.7 per 
cent, of all cases treated, and 
right and left curves were of 
practically the same fre- 
quency. It occurs later than 
the total scoliosis, as shown 
by the ages of the patients 
observed. It occurs more fre- 
quently in females than in 
males (Scholder: 13.8 per 
cent, boys, 27.7 per cent. 
girls. Schulthess: . 6.3 per 
cent, males, 12.7 per cent, 
females). The greatest deviation from the straight line is most 
often found at about the second lumbar vertebra, and as the lum- 
bar region is short, the curve must be in general a sharp one. 

The trunk is displaced to the side of the convexity of the curve and 
the line of the waist flattened on that side, while the waist on the con- 
cave side of the curve is sunken in, and folds may form in the skin of 
the flank on this side. This is expressed by an apparent prominence 
and greater size of the hip on the concave side, and it is popularly 
said that one hip has ''grown out" or one hip is ''higher" than the 
other, meaning in anatomical terms that the crest of one ilium is 




Fig. 47. — Left Lumbar Scoliosis not Return- 
ing to the Median Line. 
The lines indicate the median plane and the 
flexibility to each side. 



DORSAL CURVES 



63 



more prominent than the other. This inequality of the hips and 
waist-line is the most striking feature of lumbar curves, and unless 
corrected, forms an unsightly deformity in women with prominent 
hips, and makes it necessary to make the skirt longer on one side than 
on the other. The relative height of the shoulders is not noticeably 
affected by lumbar curves. 

As the patient stands, a fullness of the back is noticed in marked 
cases on the convex side of the curve caused by the rotation of the 
vertebrae, which carry the heavy transverse processes around and 
make prominent the overlying structures. In the position of ex- 




Fig. 48. — Left Lumbar Curve with Slight 
Right Dorsal Curve. 



Fig. 49. — Left Dorsal Scoliosis. 



treme forward bending the side of the back which is on the convexity 
of the lateral curve is prominent upward, but lumbar rotation is 
always less prominent than dorsal, and to the untrained eye even in 
the severer cases seems slight (Fig. 56). In side bending, mobility is 
greater toward the side which makes the curve worse than to the side 
which improves it (Fig. 61). 

DORSAL CURVES 



A single dorsal curve is more frequent than the single lumbar type, 
but is much less frequent than dorsal curves in combination with other 



6 4 



DESCRIPTION AND SYMPTOMS 



forms; that is to say, dorsal curves are more often than not accom- 
panied by reverse or compensating curves above or below. In the 
Schulthess figures there were 19 per cent, of single dorsal curves and 
30 per cent, where dorsal curves existed with others. The curves 
are as frequently to the right as to the left when they exist alone. 
The point of greatest curve is from the sixth to the eighth dorsal ver- 
tebra in the majority of cases. 

In a marked right dorsal curve, as seen from behind, the thorax 
is displaced to the right, and the right arm hangs farther from the 

side than the left; the right 
shoulder is raised and the 
waist-line on the right is less 
concave and much flattened 
in the severer cases, the ribs 
coming close to the crest of 
the ilium and obliterating the 
natural waist indentation. 
The rotation is made evident 
by a prominence, in the back, 
of the right side of the thorax, 
which may be seen as the pa- 
tient stands erect (Fig. 50). 
Unlike the rotation in lumbar 
cases, the rotation element in 
dorsal cases is a very marked 
feature of the deformity, and 
a sharp prominence extends 
down the right side of the 
thorax, composed of the angles 
of the ribs, which pushes the 
scapula backward and to the right. The left side of the thorax as 
seen from behind is flat or concave, the left scapula sunken and ro- 
tated with the glenoid cavity downward and the inferior angle in- 
ward. A fold in the skin frequently runs inward and upward from 
the waist-line. When the patient bends forward until the trunk 
is horizontal, the rotated ribs are very prominent upward on the 
right, and a long arch of rib angles is seen which is much more 
marked than in the standing position. On the left side the ribs are 
sunken and fall away, making a flat and even depressed surface to 
contrast with the striking prominence of the right side. 

In a right dorsal curve the right shoulder will inevitably be higher 




Fig. 



50. — Advanced Right Dorsal Scoliosis 
in an Adult. 



DORSOLUMBAR CURVES 



65 



than the other unless a left compensating cervicodorsal curve exists 
above it. The absence of a high shoulder on the convex side there- 
fore should always lead to an examination for a compensating 
curve above. 

As seen from the front, the deformity is even more evident, the 
thorax is displaced to the right, the right shoulder is higher than the 
left, and the left side of the thorax more prominent in front than 
the right. In severe cases the lower 
end of the sternum is generally dis- 
placed toward the convexity of the 
curve — in this case to the right. The 
contour of the chest is changed, and 
the longest thoracic diameter is the 
oblique antero-posterior line from the 
point rotated backward on the right 
to the point rotated forward on the 
left — in this case from the right scap- 
ula to the left nipple. This descrip- 
tion is, of course, to be reversed for 
left dorsal curves. 

The dorsal physiological curve is 
most often increased, making the 
rounded and distorted back spoken of 
as kyphoscoliosis (Fig. 51). It may, 
however, be flattened, and even 
slightly concave forward in the dorsal 
region. Loss of height and shortening 
of the trunk are evident in the severer 
cases. 

The aspect is wholly different from 
that seen in lumbar cases, where, as 
has been said, the chief noticeable dis- 
tortion is in the hips and waist-line; in dorsal cases the distortion is. 
most noticeable in the thorax and shoulders. 




Fig. si. — Kyphoscoliosis. 



DORSOLUMBAR CURVES 



Dorsolumbar scoliosis is a form seen as a simple curve with con- 
siderable frequency (20 per cent.), being, therefore, much more com- 
mon than simple lumbar, but about as frequent as simple dorsal 
scoliosis. It naturally partakes of the character of the two forms 



66 



DESCRIPTION AND SYMPTOMS 



just described and affects nine females to one male. The seat of 
greatest curve is generally at the dorsolumbar junction. It is four 
times as frequently convex to the left as to the right. The trunk and 
lower thorax are displaced toward the side of the convexity of the 
curve and overhanging the pelvis, and the waist-line on that side is 
flattened or obliterated, while on the concave side the outline cuts in 

sharply above the pelvis, fre- 
quently forming folds in the 
skin. The attitude is more 
like that of an exaggerated 
total scoliosis than like either 
the dorsal or lumbar form. It 
is not so prone to be associ- 
ated with compensatory 
curves as are the other forms. 

CERVICODORSAL CURVES 

Cervicodorsal scoliosis is a 
comparatively rare form of the 
deformity, occurring in only 
3.6 per cent, of all cases. It 
is convex to the left more 
often than to the right in the 
relation of 3 to 2, and the 
greatest curve is most fre- 
quently located at the third or 
fourth dorsal vertebra. The 
head is carried forward and 
tipped to the concave side of 
the curve. The neck is obvi- 
ously shortened, and the outline from the base of the skull to the 
shoulder is fuller and less crescentic in outline on the convex side 
of the curve than on the other. The shoulder on the convex side 
of the curve is raised and the other lowered, and the scapula of the 
raised side is conspicuously higher. The arm of the convex side 
hangs farther from the side than the other. The rotation appear- 
ances are marked, and the sharp angles of the upper ribs are promi- 
nent in the lower part of the curve, while above the rotation is less 
evident because there are only the transverse processes of the 
cervical vertebrae to make a projection. The trunk is displaced to 
the side of the convexity of the lateral curve. 




Fig. 52. — Left Dorsolumbar Scoliosis. 



COMPOUND STRUCTURAL CURVES 



6 7 



COMPOUND STRUCTURAL CURVES 

The pictures of compound curves cannot, of course, be as simple 
or uniform as those of the simple types. A right dorsal left lumbar 
curve, for example, will present a combination of the appearances 
described in both dorsal and lumbar curves; a right cervicodorsal left 
dorsolumbar, the sum of the pictures of the two factors. If the dorsal 




Fig. S3- — Cervicodorsal Curve due 
to Defective Ribs and Malforma- 
tion of Vertebrae. 



Fig. 54. — Right Dorsal Left Lumbar 
Scoliosis. 



element predominates, the appearances will be more dorsal than lum- 
bar, as is usually the case, and every grade of variation is to be seen, 
the predominant curve setting its stamp on the clinical appearance. 
The right dorsal left lumbar curve is the one most frequently seen. 
Dorsal scoliosis with compensating curves formed 30 per cent, of all 
cases in the Schulthess tables, and of these the dorsal curve was to the 
right in 80 per cent, of the cases. The greatest point of curve in these 



68 DESCRIPTION AND SYMPTOMS 

was from the sixth to the eighth dorsal vertebra, and the most fre- 
quent reverse curve associated was in the lumbar region. It is a type 
of curve most frequently seen in older children, the bulk of the cases 
being from ten to sixteen years old, but it may be seen in very young 
children. The increased susceptibility to compound curves with in- 
creasing years is shown by Scholder's statistics of school children: 

8 years old 0.4 per cent. 

9 years old " 1 . 1 per cent. 

10 years old ..1.2 per cent. 

11 years old 2.4 per cent. 

12 years old 2.1 per cent. 

13 years old 3.3 per cent. 

14 years old : 3.3 per cent. 

Women are more frequently affected than men, the proportion 
being 7 to 1. 




Fig. 55- — Dorsal Rotation Shown by Fig. 56. — Lumbar Rotation Shown by 

Prominence of Right Side in Bending Prominence of Left Side in Bending 
Forward. Forward. 



The appearances shown in the illustration (Fig. 54) will serve to 
demonstrate how the appearances of two types of simple scoliosis are 
brought together in the same patient. In a right dorsal left lumbar 
curve, the appearances of the thorax are those described for a simple 
dorsal curve, but the overhang of the thorax is modified by the dis- 
placement of the lower trunk in the opposite direction incident to the 
left lumbar curve. The resultant position may be, as in the simple 
curves, either accompanied by an increase or diminution of the 
physiological curves. 

That scoliosis may change from one clinical picture to another in 



COMPOUND STRUCTURAL CURVES 



69 



the same patient in the course of years is well established. Not only 
does the total curve frequently change to a compound type as men- 
tioned, but the structural curves change the body outline most fre- 




Fig. 57. — Severe Dorsal Rotation on Right Side in Forward Bending. 







Fig. 58. — Schulthess' Tracing of a 
Girl Six Years Old. — (Schulthess.) 



Fig 



59. — Tracing of the Same Case Eight 
Years Later.- — (Schulthess.) 



quently by the addition of compensatory curves, e.g., the illustration 
shows the change of a left dorsal right lumbar curve to a curve of the 
same type causing, however, a different distortion. In general, how- 
ever, the later distortion is an exaggeration of the earlier. 



70 DESCRIPTION AND SYMPTOMS 

The relative frequency of the common types as tabulated in 1137 
cases coming for treatment by Schulthess was as follows: 

Total scoliosis 15 . 39 per cent. 

Lumbar 11. 7 per cent. 

Dorsal 19.0 per cent. 

Dorsolumbar 20.0 per cent. 

Cervicodorsal 3.6 per cent. 

Compound , 30.0 per cent. 



CHAPTER VI 
EXAMINATION AND RECORD OF SCOLIOSIS 

In undertaking the examination of a case of scoliosis it is important 
to obtain a fairly complete history of the child's early life, as throwing 
light on the cause of the deformity, and secondly, as giving informa- 
tion as to the child's condition at the time of beginning treatment, as 
indicating the probable resistance to fatigue, the existence of factors 
likely to complicate treatment, etc. ; and, also, it is important to ob- 
tain as accurate a record as possible of the curve at the beginning 
of treatment and at subsequent stages. These two matters will be 
dealt with in the order named. 

History. Family History. — The occurrence of scoliosis in other 
members of the family is of interest as possibly indicating a heredi- 
tary origin, i£ tuberculous family history would make one particu- 
larly careful about the child's hygiene. 

Personal History. — -The character of the labor if difficult may 
point to the possibility of some injury occurring at birth. The health 
of the child as a baby, whether it was bottle fed or nursed, and the 
date of the first teeth are important in their bearing on rickets, as are 
the existence of bowlegs or other signs indicating rickets. The his- 
tory of acute illnesses in childhood are significant in showing whether 
the child has been sickly or not, and any mysterious feverish attack 
may have been infantile paralysis. The age at which the curve was 
noticed and its subsequent progress are proper subjects of inquiry, 
but the information obtained is rarely reliable. 

It is important to note the child's mental make-up, whether nerv- 
ous and apprehensive or easy going and careless, as it has a bearing 
on the formulation of treatment. Evidences of overwork at home 
or at school are factors of importance. 

The height and weight should be taken, first to show whether there 
is a reasonable period of growth ahead of the individual child, and sec- 
ond, to show whether the child is backward in growth or decidedly 
oversize. Great excess of height or weight, or of both, is important 
because decidedly overgrown children as a rule show diminished resist- 
ance to physical exercise and seem particularly liable to defects of 
posture. The height and weight should be taken and compared to 
the average given in the table. 

7i 



72 



EXAMINATION AND RECORD OF SCOLIOSIS 
Average Heights and Weights. — {T. M. Rotch) 



Boys 




Girls 






Age 






Height 


Weight 




Weight 


Height 


Inches 


Pounds 




Pounds 


Inches 


19-75 


7-i5 


Birth 


6-93 


19.25 


24.75 


14.30 


5 mos. 


13-86 


23-25 


29.53 


20.98 


1 year 


19.80 


29.67 


33-82 


30-36 


2 years 


29. 28 


32.94 


37.06 


34-98 


3 years 


33-15 


36.31 


39-31 


37-99 


4 years 


36.36 


38.80 


41-57 


41.00 


5 years 


39-57 


41.29 


43-75 


45-07 


6 years 


43.18 


43-35 


45-74 


48.97 


7 years 


47 • 30 


45-52 


47.76 


53-8i 


8 years 


51-56 


47.58 


49-69 


59.00 


9 years 


57.00 
62. 23 


49-37 


51.68 


65.16 


10 years 


51-34 


53-33 


70.04 


11 years 


68.70 


53-42 


55-n 


76.75 


12 years 


78.16 


55-88 


57-21 


84.67 


13 years 


88,46 


58.16 


59-88 


94.49 


14 years 


98.23 


59-94 



The weights at birth, and in the first, second, and third years, 
were without clothing. The ordinary school clothes were worn in 
the weighing from five to fourteen years. As the tables were made 
up from children in the public schools, children in private practice 
will as a rule somewhat overrun these figures. 



EXAMINATION 



GENERAL CONDITION 



In the examination it is important to note the nutrition and devel- 
opment, that is, whether the child is fat or thin, flabby or firm, pale 
and anemic or of good color and apparently robust. The nervous 
condition of the patient may be estimated by the presence or absence 
of apprehension, crying, twitching, or tremor, but restlessness in 
young children means nothing. The condition of the heart should 
always be examined because otherwise, harmful exercise might be 
prescribed for a child with organic heart disease. The following 
points should also form part of a routine examination. 

Condition of lungs and chest expansion. Comparative length of 
legs. The existence of flat-foot or "weak ankles." Whether or not 



EXAMINATION OF SPINE 73 

spectacles are worn. General gait and carriage. Manner of support- 
ing the underclothes and stockings, whether objectionable or not. 

EXAMINATION OF SPINE 

A patient with suspected lateral curvature should always be ex- 
amined with the back wholly bare. The clothes should be firmly 
pinned or fastened by a strap around the hips at a level low enough to 
show the top of the cleft between the buttocks and to show the out- 
line of the pelvis. In children the patients should be stripped to this 
level; in adolescent and adult young Women the chest should be cov- 
ered by an apron hanging over the front of the thorax, the strings of 
which are fastened around the neck. 

The patient should stand, back to the surgeon, squarely on both 
feet with the arms hanging at the sides. It is desirable to allow the 
patient to stand quietly for a minute or two before beginning the 
examination in order to secure the fatigued or relaxed position which 
is the characteristic one. The patient should not be handled or 
touched during the first inspection, as the contact of the hand fre- 
quently stimulates the muscles and negatives for the time being the 
relaxed position. 

Inspection of the natural standing position forms the first step 
in the examination. The surgeon notices first: 

i. The body outline, whether symmetrical or not, comparing on 
both sides the outline from the axilla to the crest of the ilium, 
whether one is flatter or more curved than the other. The trained 
eye estimates this asymmetry as a lateral displacement of the thorax 
or trunk with regard to the pelvis, and it is the safest guide. The 
appreciation of symmetry or the absence of it is essential in giving 
corrective gymnastics, and the most useful method to one trained is 
to erect an imaginary perpendicular from the cleft between the 
buttocks (anal fold), and estimate whether it cuts the trunk in the 
middle or whether more of the trunk lies to the left or right of it. 
It is obvious that if any part of the spine is laterally curved, it must 
carry with it a segment of the body to the right or left. This 
displacement will be accompanied by a change of body outline, and 
a difference in body outline on the two sides is presumptive evidence 
of a lateral curve. The outline of the body and displacement of the 
trunk to one side may always be seen more plainly from the front 
than the back, as the outline is sharper. In children this method 
should follow the one described. 

2. The surgeon next notices the level of the shoulders, whether 



74 EXAMINATION AND RECORD OF SCOLIOSIS 

one is higher than the other, and whether this is a constant position. 
The elevation of one shoulder is generally a sign of lateral curvature, 
but may exist rarely with no perceptible curve. 

3. The position of the scapulae should then be noted and the two 
sides compared. It is not of primary importance, but it is desirable 
to note their relative distance from the spine, whether one or both of 
the scapulae are displaced forward, and whether any rotation of the 
bone has taken place. 

4. The habitual position of the head should be noted, whether 
tipped to one side or held constantly rotated. 

5. The antero-posterior physiological curves should be investi- 
gated and any increase or diminution of the dorsal or lumbar curves 
noted. 

Estimation of the Spinal Curve. — Over the middle of each spinous 
process a mark is then made on the skin by a flesh pencil or by ink 
while the patient still stands as described. The skin must not be 
drawn to one side or the other in making these marks, or distortion 
may be caused by the movements of the skin over the bony points. 
This line of marks is accepted as representing the spinal curve, al- 
though it does not accurately represent the position of the bodies of 
the vertebrae (see Pathology). If a curve is present, the line of marks 
will be evident as a curved instead of a straight line, for a normal 
spine shows a line of marks forming a straight line which lies in the 
median plane of the body. 

There are now two questions to be answered: (1) Is lateral curva- 
ture present? (2) If present, what sort of a curve is it? 

The median plane of the body is readily determined by holding a 
plumb-line behind the patient, the lower part of which passes through 
the cleft between the buttocks. In the normal spine each mark 
will lie under this plumb-line. The deviation of any number of 
spinous processes from this line represents a lateral curve. This 
method of erecting a perpendicular from below is preferable to the 
method of dropping a plumb-line from the top of the column (the 
Beely-Kirchoff method). 

If a curve exists, as shown by the plumb-line, the second question 
arises as to what sort of a curve it is, whether functional or structural. 

Functional curves have four definite attributes which should be 
looked for (see p. 55), and in the absence of any one of them the 
diagnosis of a functional curve cannot be made; under these con- 
ditions the case is, therefore by exclusion, structural. The curve 
is then described (p. 61). 



EXAMINATION OF ROTATION 



75 



Cervical curves must be roughly estimated by the eye, for on 
account of the inaccessibility of the cervical spinous processes and 
the instability of the head, they cannot be definitely measured. 

Estimation of Rotation or Twist. — The surgeon, having thus 
recognized any bodily asymmetry and having identified and defined 
the curve, is in a position to investigate the element of rotation or 
twist which is essential in every case. 

The surgeon, standing close 
behind the patient, looks down 
on her shoulder-girdle from 
above to estimate whether it 
is in the same lateral plane 
as the pelvis or whether twist- 
ed forward on one side and 
back on the other. This is of 
use chiefly in postural cases, 
and in structural cases is of 
less value. By sighting the 
scapulae and back of the thorax 
on the buttocks it is easily 
seen whether any twist of the 
thorax has occurred in relation 
to the pelvis. Evidence of ro- 
tation of the ribs or lumbar 
transverse processes backward 
on the convex side of the lateral 
curve, which accompanies 
structural cases, will in severe 
cases be evident in the stand- 
ing position, but it is generally 
examined for and estimated in 
a position of forward flexion of 
the trunk, sometimes spoken 
of as Adam's position. The 
patient bends forward until the 

trunk is horizontal with the arms hanging down and the knees 
not flexed. In this position the patient remains while the sur- 
geon glances along the back from behind or in front, with his head 
on a level with the spine, and looks to see whether either side of the 
trunk is more prominent upward in the lumbar, dorsal, or cervical 
region. Any such upward prominence represents rotation or twist 




Fig. 60. — The Plumb-line in the Cleft 
of the Buttocks to Determine the Me- 
dian Plane of the Body. 



76 EXAMINATION AND RECORD OF SCOLIOSIS 

and is a most important matter. If it occurs on the concave side of 
the lateral curve and involves the curved region, it will be slight and 
evenly distributed through the spine and designates a functional or 
postural curve. That is, in a left total postural curve the right side 
of the back will probably be more prominent upward in the forward 
bent position. 

If it occurs as a well-defined local upward prominence occupying 
the curved region, it designates a structural curve at that location, 
the curve being convex to the side on which the prominence occurs 
and occupying the same anatomical area. That is, a right dorso- 
lumbar upward prominence designates a right dorsolumbar struc- 
tural curve. This must be clearly understood, for at times a curve 
which is obscure or confusing in the upright position is cleared up by 
a recognition of its rotation as seen in the forward bending position. 

Estimation of Spinal Flexibility. — The patient should now lie on 
the face and the position of the spinous processes be noted. The 
marks on the skin will represent the curve of the spine in the erect 
position, and any straightening of the spine in recumbency will be 
shown by finding that the spinous processes form a less curved line 
than that marked on the skin. In postural curves the spine will be- 
come straight in recumbency, while structural curves will be per- 
ceptibly straighter than when the patient is erect. The patient 
should now be suspended by a Sayre head sling, enough to take the 
weight off of the spine, and the straightening of the spine noted. 
This modification of the asymmetry of the trunk by suspension is 
important and should be carefully studied as to whether the asym- 
metry is practically unchanged, whether the overhang of the thorax 
is corrected, and whether the patient becomes wholly symmetrical. 
The position of the patient in suspension represents the maximum 
that may be expected from treatment in that individual case until 
further flexibility is restored by treatment directed to that end. 
The restoration of complete or almost complete symmetry by sus- 
pension points to an early case and one amenable to treatment, for 
one of the early changes in structural curves is a stiffening of the 
curved region of the spine which causes the persistence of the curve 
under suspension. So far as possible it should be noted whether the 
improvement in symmetry is produced by a straightening of the 
curve or curves or whether the modification in asymmetry is pro- 
duced by the other parts of the spine. For example, in a dorsal 
curve is the relation of the curved region changed or is the curved 



X-RAY 77 

part simply pulled away from the pelvis by a stretching out of the 
lumbar region? 

The patient should then bend forward to determine normal flexi- 
bility forward. The average child can touch the floor with the fin- 
gers while the knees are straight, while in adult life less flexibility 
is obtained. 

The flexibility of an individual spine is a matter determined by 
age, habit, and individual peculiarity. To know in a general way 
what the normal flexibility at a given age should be, is important in 
children, but in adults it is so much a matter of individual habit that 
it is of less importance. One man of fifty, for example, who has 
taken exercise may be able to touch the floor with his hands in for- 
ward bending, while another man of the same age of sedentary life 
cannot get his finger-tips within a foot of the floor in the same posi- 
tion, yet both spines are to be classed as normal. How rapid the 
change in flexibility may be owing to exercise is shown by the case of 
a healthy boy of fifteen w<ho could not touch the floor with his finger- 
tips in forward bending. He injured his knee and was obliged to 
wear a ham-splint. The exertion necessary to dress himself with his 
leg stiff so increased his forward flexibility that in ten days he could 
place the palms of his hands on the floor without exertion in forward 
bending. 

The patient then stands with the elbows out and the hands clasped 
behind the neck, and bends to one side and to the other. The char- 
acteristics of side bending have been fully described, and modifica- 
tions and restrictions of this are to be studied. Patients with curves 
can, as a rule, bend better to the side that makes the curve worse than 
to the side that improves it. 

The examination has been dealt with thus at length because rational 
treatment cannot be undertaken without a clear formulation of the 
character of the deformity, and experience shows that in the loose 
use of terms and in slipshod examinations certain failures to obtain 
proper results from treatment have their origin. 

X-ray. — The E-ray is of use in showing: (i) the existence of bony 
defects, numerical variation, or other anomalies of the spine; (2) the 
degree of distortion of the individual vertebrae; and (3) the degree 
and character of the curve. The results of x-ray photographs do not 
as a rule agree with the clinical appearances, the amount of curve 
in the x-ray being generally more than is indicated by the marks 
over the spinous processes. The amount of rotation is indicated in 
the x-ray by the position of the shadow of the spinous processes in 



78 



EXAMINATION AND RECORD OF SCOLIOSIS 



relation to the shadows of the bodies, normally the spinous process 
appearing in the middle of the body. But the element of distortion 
in #-rays must be remembered. A patient is likely to be twisted by 
lying on the back if rotation is present, and any deviation of the 




Fig. 6i. — Patient with a Right Dorsal Left Lumbar Structural Curve Bending 
to the Left and Right, Showing the Comparative Rigidity of the Lumbar Region 
to Left Bending and of the Dorsal Region to Right Bending. 



tube from the middle line of the body is expressed as distortion of 
the vertebrae, yet x-rays to-day, taken under proper conditions, 
afford the best and most reliable index of the degree of the curve and 
progress under treatment, for reasons explained on p. 77. 



RECORD OF SCOLIOSIS 79 

RECORD 

An accurate and simple method of recording scoliosis would be of 
great value to the general practitioner and to the specialist, but no 
such method exists to-day, although many have been described and 
advocated. The x-ray taken under the conditions described above 
is probably the most accurate at our disposal. Photography is an 
easy means of record, but does not fairly represent the position of 
the spine and simply gives the body outlines, and we shall see that 
a photographic overcorrection may be obtained with little or no 
change in the spine, etc. (ref. p. 184). So we must remember the 
limitations of photography, and that in the severer curves it may 
mislead us wholly as to progress, but it constitutes a fair rough 
method for the recording of bodily asymmetry caused by scoliosis. 
In taking photographs the following rules must be observed: 

1. The patient must stand at ease with the legs straight and the 
arms hanging at the sides in the relaxed position. 2. The heels of 
the patient must be on a line parallel to the lens, otherwise distortion 
is inevitable. 3. The patient must stand at a fixed distance from 
the camera in all cases if pictures are to be used as accurate records. 
4. The light should be oblique from behind, preferably diffused, and 
not the direct light of the sky if possible, which gives too violent con- 
trasts between light and shadow. A light from overhead throws 
the shadow of the shoulders onto the back and obscures the spinal 
furrow. A light directly from behind gives a flat white picture with- 
out contours. A light directly from the side throws the shaded part 
of the body into such blackness that the body outline of that side is 
lost. A crossed light obliterates contour and gives a flat and con- 
fusing picture. 5. The shadows should be diminished by a white 
reflector on the side of the patient away from the light. By this 
arrangement contour may be secured in the picture. 6. The un- 
steadiness and swaying of the patient may be obviated in a measure 
by placing an ordinary photographer's rest against the chest. 

A photograph of rotation may be obtained by having the patient 
bend forward with the head away from the camera and focusing on 
the part of the back affected by the rotation. 

If it is desired to measure and study the curve from the finished 
photograph, the method devised by Fitz may be used. 1 

Various modifications of the - simple photographic method by 

1 G. W. Fitz: "Bos. Med. and Surg. Jour.," Nov. 16,. 1905. 



8o 



EXAMINATION AND RECORD OF SCOLIOSIS 



means of screens, standard positions, etc., have been devised, 1 of 
which that of Bucholz and Osgood seems simple and accurate, 2 but it 




Fig. 62. — Leveling Apparatus (Xivellier Trapez) for the Measurement of'Rotation 
in the Forward Bent Position. — (Schulthess.) 




Fig. 63. — Schulthess' Measuring Apparatus. 

must be remembered with regard to these that the photographic 
method possesses, and always will possess, an intrinsic inaccuracy as 
explained. 

1 "Festschrift fur J. Berg." "Nordiskt medicinskt. Arkiv.," 1911. 

2 "Am. Journ. Orth. Surg.," xii, 1014, 77. 



RECORD OF SCOLIOSIS 



Si 



Tracing. — A simple and approximately accurate record may be 
made by marking the spinous processes and laying on the back, while 
the patient stands erect, a strip of crinoline gauze, through which the 
spinal marks may be seen. They are thus easily marked on the 
gauze, which may be kept as a record. The error lies in the possible 
slipping of the gauze and the necessity of placing the hands on the 
patient. 




at. 



2L. 




Fig. 64. 



-Tracing of a Left Dorsal Right Lumbar Curve Made by the Schulthess 
Measuring Apparatus. — {Children's Hospital.) 



Any one interested in the subject may find a number of methods 
described, together with the literature of the subject, in the 
reference. 1 

Rotation may be estimated in degrees with accuracy in the forward 
bent position by means of the Schulthess level square (Nivellier 
Trapez), which consists of two arms sliding on a rod to which they are 
at right angles. These arms are placed on corresponding levels of the 

1 "Ueber die Messmethoden des Ruckens," Hovorka, Wien 1904. 



82 EXAMINATION AND RECORD OE SCOLIOSIS 

back at equal distances from the spine, and the rod is provided with 
a protractor and swinging weight to show the inclination of the rod 
to the horizontal plane in degrees (Fig. 62). 

Methods which would estimate the rotation while the patient lies 
prone on the face are inaccurate, because the pressure of the table on 
the prominent side of the front of the thorax tends to rotate the chest 
and cause distortion. 

The Schulthess Apparatus for the Record of Scoliosis. — The 
Schulthess apparatus, which has been generally accepted in Europe as 
being the most accurate means of record at our disposal, consists of 
an upright frame in which the patient stands, the pelvis being fixed by 
clamps and the sternum steadied by an adjustable rod. Behind the 
patient there is a sliding bridge with counterweights which move up 
and down on the uprights. Attached to this bridge is a pointer which 
moves forward and backward and sideways. The movements of this 
pointer by an arrangement of weights and pulleys are recorded upon 
two glass panels parallel to the sagittal and frontal plane of the body 
by means of pencils moving on paper attached to the glass panels. 
By tracing from below upward the marked lines of spinous processes 
on one panel, the antero-posterior curve of the spine is recorded, 
while on the other the lateral curve is simultaneously marked. 

By a longer pointer the lateral body outline is then traced in the 
frontal plane after the position of the scapulae has been recorded. 
The two pencils in use are then thrown out of action, and by means 
of a third pencil working upon a glass plate on the sliding bridge 
horizontal contours are recorded at three levels. By means of an 
additional sliding bridge working in front of the apparatus a late 
modification of it provides for anterior as well as posterior contours, 
which may be joined to give a complete contour of the body at 
different levels (Fig. 63). 

The apparatus is expensive and complicated, and its successful 
use demands much training. 



CHAPTER VII 
PATHOLOGY 

The pathological changes in the vertebral column to be described 
as existing in scoliosis consist of modifications in shape and structure 
of the bones and soft parts. In addition to these there are found at 
times congenital anomalies of the vertebrae, changes due to rickets, 
the pathological results of empyema and infantile paralysis, all of 
which are to be regarded as primary and causative of the changes to 
be described. In other cases no pathological changes in addition to 
those described are to be found. These matters will be discussed 
more fully in speaking of etiology. 

The pathological changes occurring in scoliosis may vary from 
moderate asymmetry to extreme distortion. In general, the spine 
is curved to one side in some part of its length, or it is curved in one 
direction in one part, and in the opposite direction above or below or 
both above and below. These curves are formed by the deviation 
of the vertebrae from the median sagittal plane of the body and are 
more marked in the column of bodies than in the column of arches. 
The lateral curve may be a general sweep to one side, or it may be 
sharp and in the severer cases angular. In the severer cases it exists 
not alone in the presacral vertebrae, but may also involve the sacrum 
and coccyx. 

In addition to the lateral deviation, the curved region is rotated or 
twisted on a vertical axis, the bodies of the vertebrae always turning 
toward the convex side of the lateral curve. This rotation is the me- 
chanical accompaniment of the lateral curve, and one cannot exist 
without the other, although in some cases the rotation is out of pro- 
portion to the lateral deviation, and in other cases the lateral curve 
predominates over the rotation. 

In connection with the lateral curve, alteration in the normal 
antero-posterior physiological curves may occur, as mentioned. The 
relation of these changes to the lateral curve is but little understood. 

Such being the gross pathological changes occurring in the spine as 
a whole, it will add to clearness in considering this most complex mat- 
ter to take up individually the alterations in the separate elements. 

83 



8 4 



PATHOLOGY 




Fig. 65. — Scoliotic Spine from the Dwight Collection of Abnormal Spines in the 

Warren Museum. 
Sacralization of the twenty-sixth vertebra on the right. Thirteen dorsal and six lum- 
bar vertebrae. Fusion of several vertebras and of first three ribs on the eft. The changes 
in the vertebral bodies are characteristic of severe scoliosis. 



CHANGES IN I Hi: VKRTEBR.E 



85 



CHANGES IN THE VERTEBRAE 

Vertebral Bodies. — The scoliotic vertebrae are to be divided into 
two classes, according to their pathological changes, those in the angle 
of the curve being called wedge vertebrae, while those between the 
apices of the curves or between the apices and the normal portion are 
called lozenge-shaped or oblique vertebrae. Pure forms of wedge- 
shaped and lozenge-shaped vertebrae are rare, and both processes 
are common in the same vertebra. 

A certain amount of rotation and also a transverse displacement 
of one vertebra upon another is normally possible up to a certain 
degree on account of the elasticity of the intervertebral discs and the 





Fig. 66. — A " Wedge " Vertebra. — 

(Schulthess.) 

Second lumbar seen from in front; left 

lumbar curve. 



Fig. 67. — An "Oblique" Vertebra. 
(Schulthess.) 
Fourth lumbar seen from the front; 
from a left lumbar curve. 



play of the ligaments, but early in the affection the pathological process 
is not satisfied with the normal excursions, but rotates the vertebra 
in its structure. This rotation is expressed in the relation of the 
upper and under surfaces of the vertebral body and in a twist be- 
tween the body and arch. 

Wedge Vertebra. — The vertebrae at the apex of the lateral curve 
and just above and below it, from one to five in number, are called 
the wedge or apex vertebrae (Keil- or Scheitelwirbel), and are com- 
pressed on one side and consequently wedge-shaped. The obliquity 
may affect chiefly the upper surface when the vertebrae are below the 
apex of the curve, and the lower surface chiefly when they are above 
it, but it may affect both upper and lower surfaces nearly equally, as 
in the vertebra at the point of the curve, and some modification of 
both surfaces is generally to be noted. The thinnest part of a wedge 
vertebra is found on the side of the concavity of the lateral curve and 



86 PATHOLOGY 

generally toward the posterior aspect of the body, The side of the 
body toward the concavity is broadened and lipped in severe cases, 
and synostosis between two vertebral bodies may occur in this loca- 
tion. The apex vertebrae are rotated, as a whole, toward the con- 
vexity of the lateral curve. 

Lozenge-shaped Vertebra (torsion vertebrae, oblique vertebrae, 
Interferenz- or Schragwirbel). — The vertebrae between the apex ver- 
tebrae of the two curves or between the apex vertebrae and normal 
vertebrae are deformed in a somewhat different manner. The upper 
surface of the vertebra is displaced on the lower in such a way that 
the outline of the vertebra is lozenge-shaped, the longest diagonal 
axis being toward the apex of the lateral curve, the top of the verte- 
bra being moved sideways on the bottom. Such vertebrae may 
show oblique ridges on the front of the body. The upper part of the 
body, moreover, twists on the bottom part, below a right dorsal 
curve, the upper part of the vertebra twisting in the same direction as 
would the hands of a watch, while above the apex of the curve the 
twist occurs in the opposite direction. This is called longitudinal 
torsion. 

The vertebral foramen in the dorsal region, instead of being round 
as in the normal, in severe scoliosis becomes pointed at the side 
toward the concavity. In the lumbar region the normal triangular 
shape is distorted by being irregularly blunted at the angle on the 
side of the concavity. 

Arches of the Vertebrae. — Pedicles. — In the wedge vertebra the 
original elevation of the pedicles may be retained. As a rule, they 
are lowered on the concave side of the curve and tend to be more 
oblique on the convex side, but in the vertebra at the point of the 
curve they may be alike on the two sides. The pedicle on the convex 
side is directed straight backward and the other backward and 
outward. In the dorsal vertebrae the pedicle of the concave side may 
be narrowed, but in the lumbar region it is more generally broadened 
and the transverse process becomes smaller. In the lozenge vertebrae 
below the apex the pedicles are likely to be depressed and above it 
elevated, according to the intensity of the curve. In severe scoliosis 
the shortening of the trunk is so great that the vertebrae are pressed 
together, and, as the bodies offer less resistance to compression than 
the arches, the displacement of the pedicles on the bodies is brought 
about. 

Articular Processes. — The articular processes being connected with 
the pedicles share in any change that they undergo. Owing to the fact 



CHANGES IN THE VERTEBRAE 87 ' 

that the joint planes are so different in the dorsal and in the lumbar 
regions the pathological appearances differ widely in the articular 
facets of the dorsal and lumbar vertebrae. The crowding together of 
the articular processes on the concavity of the lateral curve results in 
an enlargement, deepening, and broadening of the joint surfaces, 
while on the convex side the facets are smaller and higher. In the 
lumbar region the superior articular facets on the concave side are 
hollowed out, while the inferior ones are correspondingly prominent 
and rounded, and the cartilage is thickened on the concave side. 
The involvement of these joints is a matter of some practical impor- 
tance, and the changes suggest an adaptation to greater demands on 
the joints on the concave side of the column. Synostosis may occur 
in these joints, and the ligaments may share in the ossification. 

Transverse Processes. — The transverse processes tend to remain 
more horizontal than the body of the affected vertebra, and as the 
vertebra becomes inclined to the horizontal plane by the changes 
described, the transverse processes strive to remain as nearly hori- 
zontal as possible. Not infrequently the transverse processes are 
shorter and thicker than normal on the convex side above and below 
the apex of the curve. 

Spinous Processes. — The spinous processes are deflected toward 
the convexity of the lateral curve in the dorsal region. This, it 
seems, may be explained as being the natural position when the spine 
is laterally curved and is retained in a scoliotic position under the 
effect of muscular pull, while the bodies of the vertebras, being 
influenced largely by weight bearing; an individual plasticity of bone, 
and certain unformulated conditions, are forced, as has been said, 
from the concavity to the convexity of the curve. 

In the lumbar region in severe cases the spinous processes are 
diverted toward the concavity. This deviation, it would seem, is 
the result of a moving to the side of the root of the spinous process 
from extreme rotation, as the tips of the processes show the endeavor 
to conform to the usual position by being in some degree approxi- 
mated to the convexity of the curve. In the dorsal region the spin- 
ous processes are also displaced downward, and the direction of each 
spinous process is therefore influenced by its contact with the one 
below it. 

The angle between the lower border of the spinous process in this 
region and the arch becomes on the convix side smaller and on the 
concave side larger than normal, and the appearance of displacement 
to the convex side is thus increased. If the arch is displaced hori- 



88 PATHOLOGY 

zontally upon the vertebral body, as described above, by the lowering 
of one pedicle and the elevation of the other the spinous process un- 
dergoes a rotation around its own longitudinal axis. The irregularity 
of these appearances may be explained by the pull of the muscles, a 
matter which is at present imperfectly formulated. 

Joints between Vertebrae and Ribs.— These, of course, are of two 
kinds: first, the joints between the heads of the ribs and the sides 
of the vertebrae; second, the joints between the tubercles of the 
ribs and the transverse processes. These are both similarly affected 
in severe scoliosis, being deepened on the side of the convexity and 
faintly indicated on the side of the concavity, especially above the 




Fig. 68. — Distorted Antero-posterior Plane of a Scoliotic Vertebra. — (Riedinger). 

apex of the curve. The articular facets on the side of the vertebral 
body are moved forward on the concave side and backward on the 
convex side. 

INTERVERTEBRAL DISCS 

These show the earliest changes, and at the points of greatest 
curve are compressed and project beyond the edges of the vertebral 
bodies as if the bodies had grown into them. On the convex side 
they are thicker than on the other. 

LIGAMENTS 

On the side of the concavity the anterior common ligament is dense 
and thick, while on the convex side of the curve it is thinned and 
shows no definite lateral border. In the lozenge-shaped vertebrae the 



MUSCLES 89 

libers run obliquely in a direction corresponding to the ridges on the 
anterior surface of the vertebral bodies. The posterior common liga- 
ment near the apex is found more to the convex side than normal 
because its insertions into the intervertebral discs do not share in the 
broadening out of the concave side of the vertebral bodies, and the 
vertebra thus grows to the concave side, while the ligament remains 
more nearly in the middle. The ligaments connecting the heads 
of the ribs and the spine are long and atrophied on the convex side 
and short and tense on the concave side. 

MUSCLES 

Where muscles are thrown out of use they atrophy and may undergo 
fatty or fibrous degeneration, When increased demands are made 
upon them they hypertrophy. When under changed conditions they 
pass over a surface of bone they may become tendinous where the 
contact occurs. Nutritive or adaptive shortening occurs when the 
ends of muscles are approximated. All these changes are to be found 
in cases of severe scoliosis, but the muscular changes in slight scoliosis 
have not been formulated. 

The change which muscles undergo in lateral curvature is first of 
all a change of direction of pull caused by the displacement of the 
thorax in relation to the pelvis toward the right or left. For example, 
if the trunk is displaced toward the left, the muscles taking origin 
from the crest of the ilium are directed toward the left at their inser- 
tion in the spine. Under normal conditions the contractility of the 
muscles would be sufficient to bring them back to their normal posi- 
tions, but in a strong lateral inclination of the lumbar segment above 
the sacrum the psoas muscle, for example, acquires a broad insertion 
and becomes fan-shaped, thereby assuming a different function. 
Under normal conditions the insertion of this muscle is more linear 
and placed at an acute angle to its direction of pull. 

Following the impairment of function of the muscles on the con- 
cave side of the lateral curve, in severe cases fatty degeneration is 
observed. On the convex side the muscles are wasted and thin, and 
sometimes, in exceptional cases, fatty degeneration is found here also. 
On the convex side more often a fibrous degeneration is found; that 
is, atrophy of the muscular tissue and the formation of larger tendons. 
In addition to all of this the stiffness of the column, which sets in 
fairly early in moderate and severe grades of scoliosis, tends to cause 
atrophy of the muscles of the back in general, the atrophy of disuse. 



9° 



PATHOLOGY 



The diaphragm assumes an oblique position and is lower on the 
side of the convexity of the dorsal curve. If the apex of the dorsal 
curve is situated high up and associated with kyphosis, the top of the 
diaphragm may be much elevated — even as high as the level of the 
third rib. 

THORAX 

In lumbar scoliosis the changes in the thorax are slight, but some 
rotation of the structure as a whole is noted in relation to the frontal 
plane of the pelvis. 




Fig. 



69. — Radiogram of Left Scoliosis, Resulting from Empyema of the Right 
Side with Resection of the Ribs. 



In dorsal scoliosis the thorax is not only displaced as a whole 
toward the convexity of the curve, but its structure is distorted. 
The thorax as a whole tends to retain its normal position with regard 
to the frontal plane of the body more closely than does the spine, 
which, as it were, rotates in the thorax. It thus undergoes a twist in 



THORAX 



91 



the opposite direction from that of the spine. This results in a 
change in its horizontal diagonal diameters, by which the one from 
the side of the convexity behind, to the concavity in front is length- 
ened, and the corresponding one on the other side is shortened. For 
example, in right dorsal scoliosis the thorax is displaced to the right 
and becomes prominent on the right side behind and the left side in 
front, and the diagonal diameter from the right side behind to the 
left side in front is lengthened. As a result of this the internal sur- 
faces of the shafts of the right ribs are brought nearer to the front of 
the vertebral bodies, and the right side of the thorax is seriously 
diminished in capacity. 




4 i '« 

Fig. 70. — Thoracic Ring in a Right Dorsal Scoliosis, seen from Above. — (Lorenz.) 



Ribs. — The ribs on the convex side of the lateral curve show a 
backward increase of their angularity, forming on the side of the 
back of the thorax a more or less sharp and prominent ridge, spoken 
of technically as "the rotation" (Rippenbuckel). In compound 
curves of the dorsal region these phenomena accompany each curve. 
From the angle forward to the sternum the ribs of the convex side 
show a loss of their normal curve. 

The ribs on the side of ( the concavity of the lateral curve show a 
straightening of their angles and an increased outward bowing of 
their shafts. The costal cartilages of the concave side in front show 



92 PATHOLOGY 

an increased curvature forward and form on the front of the chest a 
prominence at the side of the sternum (vordere Rippenbuckel). 

The ribs of the side of the convexity are spread apart and have 
a more oblique direction; on the side of the concavity they are closer 
together and tend to a more horizontal course. These phenomena 
are dependent upon the degree of inclination of the part of the spine 
to which the ribs are attached. 

Sternum. — The sternum as a rule deviates but little from its nor- 
mal position and direction except in very severe scoliosis. The 
variations in position consist — (i) In a lateral displacement; (2) in 
an obliquity of the lower end, which turns either to the convexity or 
concavity of the lateral curve; (3) in a rotation around its longitudi- 
nal axis, making one lateral border, commonly the one toward the 
concavity of the lateral curve, more prominent. A detailed study 
of the variations of the sternum may be found in the reference. 1 

SHOULDER-GIRDLE 

The marked deformity of the thorax cannot be without influence on 
the form of the clavicles and scapulae. The scapula undergoes, be- 
cause of the deformity, various changes of position' and eventually of 
form. It always acquires that position to which it is forced by the 
form of the thorax, the weight of the shoulder and arm, and the ten- 
sion of its muscles. On account of the backward prominence of the 
thorax, the scapula is moved away from the vertebral column on the 
convex side, and if the scoliosis is located high up in the dorsal region, 
the scapula moves upward also. If the thorax is strongly compressed 
from the side, the scapula may lie sidewise, so that its dorsal surface 
has a lateral and not a backward direction, or it may swing backward 
so that its inferior angle crosses the line of spinous processes to the 
other side. It may furthermore acquire a strong curve on itself if 
it lies on a thorax sharply deformed, and become convex backward. 

The clavicle, whose first function is to keep the scapula at a certain 
distance from the sternum, also changes according to the situa- 
tion of the spinal curve, and may be found more sharply curved in 
scoliosis. 

PELVIS 

Sacrum. — In low curves (generally convex to the left in the lumbar 
region) the sacrolumbar junction becomes practically the apex point, 
and here one looks for rotation, and pressure changes. The sacrum 

1 Fauconnet "Zeitsch. f. orth. Chir.," xvii, page 201. 



PELVIS 



93 



is affected in such low lateral curves in a way analogous to that of the 
other vertebrae, but modified in extent by its fixed position. In a 
right dorsolumbar curve the following changes in the sacrum were 
found and may be taken as exemplifying them (Schulthess) : 
• i. A decrease in the height of the first sacral vertebra on the con- 
cave side (cf. wedge vertebra). 

2. A broadening of the base of the sacrum on its concave side (cf. 
broadening of concave side of vertebral body). 

3. Forward displacement of the left or concave half with its cor- 
responding ala and backward 
displacement of the right or 
convex half (cf. rotation of 
vertebral bodies). 

4. Broadening of the part 
of the sacrum corresponding 
to the pedicle on the concave 
side. 

5. Lowering of the arch on 
the concave side. 

In addition to this there is 
to be seen at times a slight in- 
dication of a lateral curve of 
the sacrum, reaching its apex 
at or below the middle of the 
bone. In this the coccyx may 
share, emphasizing the curve, 
but the sacral curve is most 
easily seen by sighting along the anterior surface of the sacrum or 
looking down the vertebral canal. This curve shows slight indi- 
cations of the same changes noted in the presacral vertebrae. 

The pelvis is somewhat changed in diameter and shape in severe 
low lumbar curves in which the sacrum shows distortion. In a left 
lumbar curve the diagonal diameter from the left side behind to the 
right side in front is greater than the opposite diagonal; thus, in an 
individual case of right dorsal left lumbar curve the thorax and pelvis 
would be twisted in opposite directions. 




Fig. 71. — Oblique Pelvis Accompanying 
Scoliosis. — (Warren Museum, cast from a 
specimen in Musee Dupuytren, Paris.) 



SKULL 



In long-continued scoliosis, especially of the upper part of the 
column, asymmetry of the face and skull may exist. 



94 PATHOLOGY 

INTERNAL ORGANS 

In scoliosis, especially in moderate and severe forms, a shortening 
of the trunk is apparent which prevents the normal development and 
function of the internal organs. By the lateral displacement of the 
trunk and rotation of the thorax the pleural and abdominal cavities 
become distorted. The patients become anemic and show a certain 
disposition to tuberculous pulmonary diseases. Bachmann, 1 in 197 
autopsies in scoliotic patients of moderate and severe type has found 
in 28.3 per cent, tuberculous disease of the lungs, while in milder de- 
grees of scoliosis there were 66 per cent, so affected. 

The secondary changes in the internal organs are essentially de- 
pendent upon the narrowing. of the containing cavities. In a severe 
right dorsal curve the right pleural cavity is very much narrowed — so 
much so that in extreme cases the inner surfaces of the ribs are found 
lying close to the vertebral column. The narrowing of the pleural 
cavity on the left, that is, on the concavity, is not so important as 
that of the right. It follows that the right lung must suffer from the 
distortion more than the left. Mosse 2 found apex infiltration in 60.2 
per cent, of 100 scoliotic children between five and sixteen years old. 
Kamine v. Zade 3 found apex affections in 73 per cent, of scoliotic 
women, the lung affection being predominantly of the lung on the 
convex side of the curve. 

Affections of the pleura, adhesive pleuritis, leading to total oblit- 
eration of the pleura and atelectasis, are found very frequently. 

Undoubtedly the lungs of scoliotic patients, especially in cases of 
kyphoscoliosis, are predisposed toward a greater number of diseases 
than the lungs of normal individuals. 

Heart and Vessels. — The same narrowing of thoracic space affects 
the heart. It is frequently found pushed upward and pressed 
against the anterior chest-wall, and it is at the same time, according 
to the direction and the extent of the curvature, more or less dis- 
placed laterally. In right curves generally, the heart is displaced 
toward the left; but this is not a constant condition. Hypertrophy 
and dilatation of the cavities of the heart are very frequent, espe- 
cially of the right heart in severe scoliosis. Bachmann found it in 

56.4 per cent, of cases, while the left heart was similarly affected in 

17.5 per cent. This phenomenon was found in both right and left 
sides in 25.9 per cent. 

1 Bachmann: "Bib. med.," Abt. 1, Heft 4, 1899. 

2 Mosse: "Zeitsch. f. klin. Med.," xli, pages 1-4. 

3 Kamine v. Zade: "Deut. Arzte. Zeit.," 1902, xx. 



INTERNAL ORGANS 95 

The aorta in general, follows the curvature of the spine, particularly 
in right curves. In a left dorsal curve, however, the aorta does not, 
as a rule, lie on the convex side of the curve, but runs straight like 
the chord of an arc, more often in front or even a very little to the 
right of the spine. The large veins show less typical changes. The 
vena cava in the region of the liver, where it is relatively fixed, and 
occasionally at the entrance of the renal veins, may show a change in 
its course corresponding to the change of position of the organs. 

The most reasonable explanation for the hypertrophy of the heart 
is the insufficient depth of respiration of scoliotic patients. Even in 
relatively slight distortion of the thorax, respiration is more shallow 
than the normal, consequently the right side of the heart, in order to 
push the necessary amount of blood through the lungs, must do an 
extra amount of work. 

If the scoliosis increases, the chest space is restricted still more, and 
the expansion of the lungs, already damaged by adhesions and thick- 
ening, is impeded. The heart is also pressed against the front wall of 
the chest, and the blood-pressure is changed on account of the bends 
in the vessels, which conditions add greatly to the work of the heart. 
The difficulty which the blood finds in passing through the lungs leads 
to a great degree of venous dilatation if the condition continues long 
enough. This is especially noticeable in the veins of the head, neck, 
and .arms. 

Esophagus. — In general the esophagus has a tendency to deviate 
in the direction of the concavity of the curve, although frequently its 
form and course are but little changed. The influence upon the 
course of the esophagus is least when the radius of the curve is a large 
one and the secondary curve lies below the diaphragm. In every 
case the esophagus follows a straighter course than the aorta, and it 
crosses the aorta near the point at which it pierces the diaphragm. 1 

Intestines. — The abdominal contents are, in consequence of re- 
stricted space, pressed downward and forward, and added to this is 
the influence of the approximation of the chest to the pelvis and the 
side displacement of the vertebral column. The downward pressure 
results in crowding the intestines into the true pelvis. The lateral 
displacement of the thorax affects chiefly the transverse colon, which 
may become almost vertical. 

Liver. — In right curves the liver is pushed toward the left, the left 
half is better developed than the right half, and finally the organ on 
the right side may be indented by the ribs. 

1 Hacker: "Wien. med. Woch.," 1887, page 46. 



g6 pathology 

Kidneys. — In right dorsal scoliosis the right kidney is often dis- 
placed upward along the spine and the left one downward, and while 
the right kidney suffers as a rule slight changes, the left is more likely 
to be affected severely from rib pressure. Cystic degeneration and 
floating kidney are common. Bachmann enumerates, among 180 
observations, 14 cystic kidneys, 31 cases of granular atrophy, 18 cases 
of simple atrophy, and 6 cases of hydronephrosis. 

Spleen. — The spleen may be higher than normal. Perisplenitis, 
atrophy, and cyanotic induration have been observed (Bachmann). 

Stomach. — The position of this is influenced by that of the liver 
and duodenum. The pylorus is depressed,' while the cardiac end 
generally lies high. 



CHAPTER VIII 
ETIOLOGY 

The subject of the etiology of scoliosis easily lends itself to elabora- 
tion and in discussing it there is difficulty in preserving simplicity. 
It will clear matters very much to remember that there are two types 
of scoliosis, one the postural, better spoken of as false scoliosis which 
is really only faulty attitude and has its own causes, and second, the 
structural or true scoliosis where there is pathological change in the 
vertebras, and where a different set of causes must be looked into. 
That false scoliosis passes into true scoliosis at times has been already 
mentioned, but that not all true scoliosis originates in false scoliosis 
is also undoubted. 

In real scoliosis there are met many cases so severe that they can- 
not be accounted for by the assumption that they are the natural 
result of the maintenance of a growing normal spinal column in a 
malposition over a period of years, and one must look for an addi- 
tional cause. These causes are as a rule to be found in (a) congenital 
anomalies of the spine and its appendages; (b) rickets; (c) empyema; 
id) infantile paralysis, and (e) cases where the deformity of the bones 
is so great that one must assume the existence of a diminished indi- 
vidual resistance of bone. In the last class of cases many writers 
would assume in all instances the existence of rickets as explaining 
the softness of the bones, but as in many of the cases evidences of 
rickets are not to be found, it seems fairer to meet the situation by 
the statement that there is apparently a diminished resistance of 
bones in such cases of unknown origin, but that no demonstrable 
evidences of rickets are present. 

As a practical application of the foregoing one may assume that a 
short leg, e.g., will cause asymmetry and faulty attitude, i.e., false 
scoliosis, and in certain cases may be apparently accountable for mild 
degrees of real scoliosis, but that it is not competent to cause a mod- 
erate or severe scoliosis in a child whose bones possess a normal resist- 
ance to pressure, but if the bones do not possess this resistance 
because of rickets or for causes that we do not at present recognize, it 
or any similar cause may result in moderate or severe scoliosis. 
7 97 



98 ETIOLOGY 



The following conventional schematic representation of the causes 
of scoliosis is to be interpreted in the light of what has just been 



A. Congenital scoliosis. 

1. Malformation of the spine 

2. Malformation of the scapula. 

3. Malformation of the thorax. 

4. Deforming intrauterine pressure. 

5. Paralysis of intrauterine origin. 

B. Acquired scoliosis. 

1. Anatomical, physiological, or other asymmetries elsewhere 

than in the spine. 

(a) Torticollis (wry-neck). 

(b) Pelvic asymmetry. 

(c) Pelvic obliquity (short leg). 

(d) Unequal vision. 

(e) Unequal hearing. 

2. Pathological affections of the vertebras. 

(a) Rickets. 

(b) Osteomalacia. 

(c) Pott's disease. 

(d) Dislocation. 

(e) Arthritis deformans. 
(/) Tumors, etc. 

3. Pathological affections of the bones and joints of the ex- 

tremities, causing asymmetrical position. 

(a) Diseases of bones and joints of the leg. 

(b) Diseases of bones and joints of the arm. 

4. Distorting conditions due to disease of the soft parts. 

(a) Infantile paralysis. 

(b) Spastic paralysis. 

(c) Nervous diseases (hemiplegia, syringomyelia, etc.) 

(d) Empyema. 

(e) Organic heart disease. 
(/) Scars. 

(g) Throat, abdominal or pulmonary disease. 
(h) Acute or chronic inflammation of the spinal mus- 
cles (lumbago, etc.). 

5. Habit or occupation. 



SCOLIOSIS OF CONGENITAL ORIGIN 99 

A. SCOLIOSIS OF CONGENITAL ORIGIN 

The tendency of the last few years has been very strongly toward 
the recognition of the congenital type of scoliosis. In former years 
practically all cases were regarded as acquired and the congenital 
form considered as a great rarity, but this condition is coming to be 
recognized as by no means infrequent, and every year an increasing 
number of the moderate and severe types are being transferred from 
the acquired to the congenital class. This is due largely to the devel- 
opment of the rv-ray and the study of the living spine thus made 
possible. 

In certain congenital cases of marked scoliosis where a careful 
study of the spine is possible, no congenital anomaly is to be found 
and intrauterine pressure as formulated by HorTa 1 is the presumable 
cause. Intrauterine paralysis is suggested as a cause by a case of 
Hirschberger. 2 

In the majority of cases congenital scoliosis is due to defective 
formation of the vertebrae or adnexa. The period at which these 
defects originate is discussed by Kirmisson, 3 Mouchet, 4 and Seibert, 5 
the rib defects being secondary according to the view of the former.- 

1. DUE TO MALFORMATIONS OF THE VERTEBRAL COLUMN 

Scoliosis may occur as a congenital condition in connection with 
severe malformations, such as rachischisis and the like. 6 It occurs 
also as the result of less severe spinal defects, such as cervical ribs, 
spina bifida, and abnormal formation of the last lumbar vertebra. 

Congenital scoliosis may be evident — (1) immediately after birth, 
as in the case of the severest malformations (Colville 7 in 1015 cases 
of new-born children found one case of scoliosis); or (2) only when 
the child begins to walk, in the case of malformations not severe 
enough to cause a curve in the recumbent position. In these latter 
cases the curvature appears as the result of the superincumbent 
weight coming upon the defective spine or as the result of asym- 
metrical growth due to the malformation. Such cases as these are 

1 "Lehrbuch der orth. Chir.," 1894. 

2 "Ztsch. f. orth. Chir.," vii, 1. 

3 "Revue d'Orth.," 1910, 21. 

4 "Revue d'Orth.," 1910, No. 4. 

5 "Ztsch. f. o. Chir.," 191 1, xxviii, 415. 

6 Schmidt: "Allg. Path, und path. Anat. d. Wirbelsaiile," Lubersch's "Ergeb. 
zur allg. Path.," 4, Jahrg., 1897. 

7 Colville: "Rev. d. Orth.," 1896, 7. 



IOO 



ETIOLOGY 



perhaps not strictly congenital, but might be better spoken of as 
scoliosis due to a congenital cause. 

Another common location of congenital defects is in the cervico- 
dorsal region (Fig. 53). The formation of a cervical rib is often 
associated with a splitting of the vertebral bodies, as shown by the 
x-ray, and in some cases the cervical rib is accompanied by a rudi- 
mentary extra vertebral body. 1 The shoulder on the side of the 

cervical rib is elevated, and the 
curve is a sharp cervicodorsal 
one with a compensatory oppo- 
site curve below. Cervical 
ribs may or may not be ac- 
companied by scoliosis. In 
thirty-five preparations and 
eleven clinical cases with cer- 
vical ribs Eckstein 2 twice found 
scoliosis. 

At the lumbo-sacral junc- 
tion anomalies are frequent. 3 
Waldeyer found that the first 
sacral vertebra possessed lum- 
bar characteristics in thirty- 
three out of 265 cases, and in 
eighty-three cases, of Adolphi 
(48 men and 35 women) the 
twenty-fifth vertebra was the 
last pure lumbar in 3.6 per 
cent., the twenty-fourth in 92.8 
per cent., and the twenty-third 
in 3.6 per cent. Abnormalities 
of the sacral vertebrae are dis- 
cussed by Breuss and Kolisko. 4 

Sacralization of the fifth lumbar vertebra, especially if unilateral, is a 
competent cause of scoliosis. 5 Numerical variation of the vertebrae, 
especially if unilateral as pointed out by Bbhm, 6 is a competent cause 

1 Drehmann: "Verhdl. d. Deutsch. Gesell. f. orth. Chir.," 5th Congress, 1906, 
page 12. 

2 "Zeitsch. f. orth. Chir.," 1908, xx, 177. 

3 Cramer: "Verhdlungen d. Deutsch. Geo. f. orth. Chir.," 1908, 68. 

4 " Pathologische Beckenformen." 

5 Adams: "Am. Journ. of Orth. Surg.," July, 1914. 

6 ''Boston Med. and Surg. Jour.," Nov. 22, 1908; "Berl. klin., Wchsft.," 1910, 
2; "Berliner Klinik," Feb., 1910. 




Fig. 72. — Scoliosis Due to Congenital 
Defects in Spine and Thorax, the Ribs 
being Bifurcated and Defective. 



MALFORMATION OF THE SCAPULA AND THORAX 



IOI 



of scoliosis; but, as shows by Adams, numerical variation is not as a 
rule accompanied by scoliosis because in the Dwight collection of 
sixty-four spines in the Warren Museum of the Harvard Medical 
school, all showing numerical variation, there were only seven which 
could possibly be classed as scoliotic. 1 

Melting together of vertebral bodies and the absence of part of a 
vertebra are the chief remaining 
causes of congenital scoliosis 
so far formulated. 

2. MALFORMATIONS OF THE 

SCAPULA 

Congenital elevation of the 
scapula (Sprengel's deformity) 
will cause a scoliosis which is 
usually a high cervicodorsal 
curve with compensating dor- 
solumbar curve. One scapula 
is occasionally absent or mal- 
formed (Fig. 73). 

3. MALFORMATION OF THE 
THORAX 

Occasionally great irregu- 
larity characterizes the ribs of 
one or both sides. Some may 
be bifurcated, others are united 
by a bridge of bone, while in 
others certain ribs are missing 
scoliosis. 

Heredity must also be considered, as it is known that scoliosis is 
apparently inherited in some families, Schulthess estimating that 
from 10 to 15 per cent, of scolioses are hereditary. Congenital 
defects of form can be inherited, and would reasonably lead to similar 
forms of scoliosis, while an inherited weak skeleton or a disposition to 
rickets would not necessarily lead to a reproduction of the form of 
scoliosis. There are cases, however, in which the form also seems to 
be hereditarv. 




Fig. 



73. — Congenital Elevation of the 
Scapula Causing Scoliosis. 



Such irregularities are a cause of 



'Boston Med. and Surg. Jour.," Apr. 28, 1910. 



102 ETIOLOGY 

B. ACQUIRED SCOLIOSIS 

Scoliosis is to be classed as acquired when the deformity comes on 
after birth from some cause not apparently congenital, and this 
includes, so far as we know now, the greater number of cases. The 
experimental production of scoliosis in animals has been demon- 
strated and is discussed elsewhere (page 48). The acquired varieties 
of scoliosis may be considered as follows: 

1. ANATOMICAL OR PHYSIOLOGICAL ASYMMETRIES ELSEWHERE 
THAN IN THE SPINE 

(a) Torticollis, — or wry-neck, a condition characterized by the con- 
traction of one sternocleidomastoid muscle, causes a tilted and 
twisted position of the head and necessitates a compensatory lateral 
curve of the spine to preserve the balance and enable the head to 
assume a more normal position. Unilateral torticollis, if sufficiently 
long continued, is always accompanied by scoliosis. 

(b) Asymmetry of the Pelvis. 1 — The spine is not always located in 
the middle of the pelvis, but at times is found at one side of the 
median sagittal plane of the body (amesiality of the pelvis). The 
pelvis may be in other respects asymmetrical. In these cases a 
compensating lateral curve is necessary in order to allow the head 
to be held over the center of the body 1 (Fig. 74). 

Hasse 2 held that he had rarely seen a symmetrical pelvis, and 
Naegele in a collection of fifty pelves, could not find one to show to 
his students as normal. 

(c) Obliquity of the Pelvis. — Any condition which causes the 
pelvis to be held higher on one side in the horizontal plane is a com- 
petent cause of scoliosis, because such obliquity necessitates a lateral 
curve of the spine to secure normal balance. A short leg must 
therefore be counted as a possible cause of scoliosis. But it must be 
remembered that a difference in the length of the legs is very common 
in children, 3 and that the frequency of permanent scoliosis is much 
less than the frequency of short legs (Fig. 75). The association of 
short legs and scoliosis has been investigated, with varying results; 
and Schulthess estimates, without analyzing his cases, that from 1 to 
5 per cent, show this association. The measurement taken with a 
tape-measure from the two anterior superior spines to the inner 
malleoli while the patient lies on the back is inexact and of little 

1 "Arch. f. Anat. and Phys.," 1801. 

2 "Das Schrag. verengte Becken.," 1839. 

3 Bradford and Lovett: "Orth. Surgery," 3d ed., page 476. 



SCOLIOSIS CAUSED BY ASYMMETRY 



I03 



value as determining the real position of the pelvis in standing, and 
much importance must not be attached to it. The most reliable 
method that we have of determining the horizontal plane of the 
pelvis and the obliquity which must exist when there is really a 
short leg is to make level. the two anterior superior spines when the 

patient stands erect by means of 
pieces of thin board placed under 
one foot, but even this is inac- 
curate on account of the fre- 
quency of asymmetry of the pelvis 
just alluded to. It is an occa- 





Fig. 74. — Scoliosis Due to Asym- 
metry of the Pelvis, the Right 
Side Being Smaller. 



Fig. 75. — Left Lumbar Scoliosis 
from Inequality in the Length of 
Legs. 



sional experience to find that the spinal curve is increased by 
putting a block under the foot on the side shown to be short by 
measurement, and that the spinal curve is thus improved by mak- 
ing the long leg longer. 

(d) Unequal hearing causes a tilting or twisting of the head which 
may produce a temporary lateral curve in the cervical and upper 
dorsal regions. 



104 ETIOLOGY 

(e) Unequal vision, necessitating a tilting of the head to bring 
vertical objects into clearer vision, may cause a lateral curve. The 
school observations at Lausanne are of interest in this connection, as 
a steady increase in the percentage of scoliotic and myopic children 
was found from the lowest classes upward, as is shown by the table. 

Class 

I 

II 

Ill 

IV 

V 

VI 

VII 



Scoliotic 


I 


Myopic 


8 . 7 per 


cent. 


3-o 


per 


cent. 


18.2 


tt 


4-5 




tt 


19.8 


a 


5-2 




11 


27.2 


tt 


6.0 




" 


28.3 


tt 


8.5 




tt 


32.4 


a 


13-7 




tt 


31.0 


11 


19.4 




n 



The relation between scoliosis and myopia has not yet been deter- 
mined. 

It is obvious that astigmatism may be a cause of head tilting. The 
subject has been carefully worked out by Gould, 1 whose conclusion 
is that in asymmetrical astigmatism the axis of the dominant eye 
determines a tilting of the head to the right or left, but that this 
does not occur in symmetrical astigmatism. 

But it must be remembered that those conditions which cause the 
spine to be held asymmetrically, and which have just been men- 
tioned, are frequent, while structural scoliosis is not by any means so 
frequent. And one must assume that in those cases where severe 
or moderate structural changes have occurred as a result of this 
asymmetrical position that the bones of the individual possess less 
than normal resistance. 

2. PATHOLOGICAL AFFECTIONS OF THE VERTEBRA 

(a) Rickets, 2 which is a constitutional disease beginning in the 
first dentition which leads to a softening of the bones, has long been 
recognized as a cause of scoliosis. But the trend of recent opinion is 
toward assigning rickets as a cause of scoliosis in a very much larger 
number of cases than was formerly done. Indeed, some writers 
would go so far as to assume that practically all organic scoliosis, not 
obviously due to a congenital defect or some such obvious cause as 

1 G. M. Gould: "Amer. Medicine," May 21, 1904; Mar. 26, 1904; April 8, 
1905; "N. Y. Med. Record," Apr. 22, 1895. H. A. Wilson: "N. Y. Med. Journal," 
June, 1906. 

2 Kirsch: "Verhdlg. d. Deuts. Ges. f. orth. Chir.," 1910, page 94; Bohm: 
"Verhdlg. d. Deuts. Ges. f. orth. Chir.," 1910, page 49. 



PATHOLOGICAL AFFECTIONS OF THE VERTEBRA 105 

empyema or paralysis, was due to rickets. The situation in this 
regard has been already discussed at the opening of the chapter. 

The typical rachitic variety of scoliosis is characterized by a sharp 
and severe curve oftenest in the lower spine, with shortening of the 
trunk. It is one of the most resistant forms to treatment and is a 
variety which begins early as the softness of the bones is most marked 
during the acute process. The recognition is made by the presence 
of the other signs of rickets found in the deformed bones elsewhere 
and by the usual diagnostic signs. 

(b) Osteomalacia, an uncommon process like rickets in causing a 
softening of the bones, but more frequently seen in adolescents and 
adults than in children, is ac- 
companied occasionally by 
lateral curvature. 

(c) Tuberculous disease of 
the spine, or Pott's disease, is 
a destructive pathological proc- 
ess attacking the bodies of 
the vertebrae. Lateral devia- 
tion of the spine associated 
with stiffness often exists in 
connection with the backward 
"hump" or kyphosis, which is 
the characteristic sign of the 
disease. This early form is 
generally atypical, with little 
rotation. In the earlv stages „ ^ 

Fig. 76. — Severe Scoliosis Due to Rickets. 

of Pott's disease, lateral devia- . 

tion is present as a symptom of irritation. In the later stages of 
Pott's disease lateral asymmetry may be present as the result of 
unilateral destruction of one or more of the diseased vertebras. 

(d) Severe tnjuries of the spine, resulting in chronic sprain of the 
vertebral column, dislocation of the vertebrae, and injury of the epi- 
physeal cartilage, may be accompanied by lateral deviation of the 
spine as a symptom. 

(e) Arthritis deformans is characterized by a progressive stiffening 
of the spine due to deposits of newly formed bone on the front and 
sides of the column, binding the vertebrae together. The interver- 
tebral discs degenerate and the vertebrae become fused; bony deposit 
occurs in the ligaments, and the articulations of the vertebrae with 
the ribs may lose some or all motion. Lateral deviation, accompa- 




106 ETIOLOGY 

nied by general kyphosis, is generally present, but is atypical and 
accompanied by little rotation (see Ischias Scoliotica, page 108). 

Other causes of this class are tumors of the spine and, it is said, 
hereditary syphilis. 

The scolioses of this class are symptomatic of a serious condition, 
and except for that of rickets, are not to be treated like ordinary pri- 
mary scolioses but would be injured by such treatment. 

3. AFFECTIONS OF THE BONES AND JOINTS OF THE EXTREMITIES 

(a) Diseases of the bones and joints of the lower extremity 

play a larger part in the etiology of scoliosis than those of the arm 
and shoulder. Lateral curvature may be caused by the shortening of 
one leg due to derangement of growth; to unilateral diseases of the 
hip-joint causing shortening, dislocation, contraction, or ankylosis in 
a position of adduction, abduction, or flexion; to unilateral congenital 
or paralytic dislocation of the hip; to coxa vara, coxa valga, and 
fractures of the lower extremity; to diseases and malformations of 
the diaphyses of the leg or thigh bones; to diseases of and operations 
on the knee-joint causing shortening, contraction in the flexed posi- 
tion, or knock-knee on one side; and to diseases and malpositions of 
the foot, especially flat-foot. 

(b) Diseases of the shoulder- joint, causing partial or complete 
ankylosis, may be accompanied by a curve of the spine in the 
dorsal region. 

4. DISTORTING CONDITIONS DUE TO DISEASE OF THE SOFT 

PARTS 

(a) Infantile spinal paralysis or anterior poliomyelitis 1 is a com- 
mon cause of lateral curvature. The paralysis occurs of tenest during 
early childhood, and the lower extremity is more often affected than 
the upper. The deformities produced are due to shortening of bone 
or to muscular paralysis. Scoliosis results in one of three ways: 

1. From inequality in the length of the legs, causing a tilting of the 
pelvis. 

2. From unilateral paralysis of the muscles directly controlling 
the vertebral column, which may cause a deviation of the spine 
either to that side or to the other side. It does not follow, as shown 
by Arndt experimentally and as recognized clinically by others, that 

1 Cordet Boise: "Revue d'Orthopedie," 1910, 5, 381. 



PARALYTIC SCOLIOSIS 



107 



a paralysis of the muscles of one side of the back is followed by a 
curve convex toward the paralyzed muscles, as would naturally be 
expected. The curve is the result of the effort of the patient to ad- 
just his center of gravity to the new conditions induced by unilateral 
paralysis. This equilibration may result in a curve convex either 
to the right or left in a right-sided paralysis. 

3. From faulty spinal attitudes assumed in consequence of paraly- 
sis elsewhere, as in paralysis of the arm. 




Fig. 77. — Right Dorsal Left Dorso- 
Lumbar Curve Due to Infantile 
Paralysis. 



Fig. 78. — Severe Right Curve Due to 
Infantile Paralysis. 



(b) Spastic paralysis or Little's disease is the result of a cerebral 
lesion and a descending degeneration of the lateral columns of the 
spinal cord. The growth of bones is often retarded, and muscular 
irritability and stiffness are noted with contractions. Scoliosis is an 
occasional accompaniment. 

(c) Other nervous diseases, represented by a much smaller num- 
ber of cases accompanying lateral curvature, are multiple neuritis, 
meningitis, cerebrospinal meningitis, syringomyelia, pseudomuscular 
hypertrophy, locomotor ataxia, Friedreich's ataxia, tumors of the 
spinal cord, and obstetrical paralysis. 

A marked lateral deviation of the spine, extensively studied by the 



io8 



ETIOLOGY 



Germans and termed by them Ischias Scoliotica, 1 is a form without 
much rotation which accompanies the inflammatory affections of the 
lumbar region vaguely classed as' " lumbago" and " sciatica." It is 
frequently found in arthritis of the spine and in acute and chronic 
sprains of the spine. 

A similar malposition is observed in hysteria 2 (Fig. 81). An 
analogous deviation is found in disease of the sacro-iliac joint in 




Fig. 79 — -Severe Right Curve (see Fig. 
78) Due to Infantile Paralysis. 
Showing abdominal and thoracic con- 
struction on left. 



Fig. 80. — Same Case as Figs. 78 and 
79 Showing Deformity of Lower Rib. 
Induced by Pressure. 



which the lateral curve is induced by the instinctive effort to spare 
the affected joint. 

(d) Empyema 3 is followed by lateral curvature in certain cases, 
both without operation and after the operation for removal of a rib. 
The scar contraction seems to be the cause of the chief curve, which is 
always to the right in left empyema and vice versa. There are likely 
to be compensating curves above and below the main curve, the 

1 Stein: "Zeitsch. f. orth. Chir.," xxv, 1910, 479 (with literature). 
2 Binswanger: "Hysterical Scoliosis," "Deutsch. med. Wochens.," Vereins- 
beil., 1902, 5. 

3 Walther: "Zeitsch f. orth. Chir.," 1910, xxv, 401. 



OCCUPATIONAL SCOLIOSIS 



IOQ 



height oi the shoulders is generally very different and the hyper- 
trophy of the sound side of the chest is a marked feature (Fig. 82). 

(e) Scars rarely cause scoliosis, although it sometimes is found 
after extensive unilateral burns when the deviation of the spine is 
brought about by contraction of the scar tissue (Fig. 83). 

(/) Phthisis and diseases of the pleura and obstructions in the 
nasopharynx are to be mentioned among the diseases of the respira- 
tor v organs sometimes followed bv scoliosis. 




Fig. 81. — Hysterical Scoliosis. 



Fig. 82. — Right Dorsal Curve Due to 
Left Empyema. 



(g) Organic heart disease, especially in children, is a competent 
cause of lateral curvature (Fig. 84). 



5. HABIT OR OCCUPATION 

That the continued maintenance of an asymmetrical portion of the 
spine through the period of growth may result in some degree of 
bony deformity of the growing spine is a self-evident proposition, 
dependent on the fact that growing bone is plastic and follows the 
line of least resistance. But that such conditions are likely to result 



no 



ETIOLOGY 



in moderate or severe scoliosis in normal children is not, in the opinion 
of the writer, likely. That they may result in "false scoliosis" or 
slight scoliosis is apparently reasonable to expect. 




Fig. 83. — Scoliosis Due to Extensive 
Burn of Left Chest Received at the 
Age of 17. Patient now 19 Years Old. 



Fig. 84. — Severe Scoliosis Associated 
with Organic Heart Disease. Death 
Occurred from the Latter. 



The commonest causes of " occupation" scoliosis are to be found 
in children in the assumption of faulty attitudes at school and at 
home, violin playing, the use of a side saddle in horseback riding, 
carrying heavy weights asymmetrically, etc. 

The relation of scoliosis to school life has been much discussed and 
will be considered by itself. 



CHAPTER IX 
OCCURRENCE 

Scoliosis in Quadrupeds. 1 — Scoliosis in animals other than man 
has been observed, but is rare. Eighteen cases were found in litera- 
ture by Hartel in 1909. Ten of these were foetal malformations 
found in new-born horses, goats, deer, and calves; curves due to 
rickets were found in pigs, and in cattle an inflammation and growing 
together of vertebrae or parts of vertebrae. Further are to be added 
scoliosis in a colt one and one-half years old and in a goat, and a case 
of scoliosis due to congenital defect of the vertebrae in the cervical 
region in a horse. 

Such curves in mammals consist of short sharp curves accom- 
panied by torsion, but what corresponds to real "habitual scoliosis" 
in the human being has not been definitely established as existing in 
quadrupeds; a real static deformity, however, is the sway back ob- 
served in horses. 2 

In the lower vertebrates scoliosis has been observed in fishes, 
snakes, and eels. Among domestic fowls scoliosis is not uncommon 
in hens, ducks and geese, and Klapp and Hartel collected a dozen 
scoliotic skeletons from this source in one year. The study of this 
deformity in fowls has a certain bearing on scoliosis in man because 
of the fact that in birds the weight is borne on two limbs, although 
the position of the spine is much more horizontal. In quadrupeds 
the horizontal position of the spine and its support on four limbs 
makes the static relations wholly different from those existing in man. 

In fowls the examinations of Hartel show two distinct classes of 
cases: first, an atypical scoliosis due to vertebral defects and uni- 
lateral numerical variation of the vertebrae, an important matter as 
bearing on the similar condition in man; and, second, a typical 
scoliosis accompanied by rotation of the vertebral bodies to the con- 
vex side of the curve, which is more frequent than the first-named 
variety. As bearing on the etiology of the latter, changes attribu- 
table to trauma, inflammatory processes, and rickets were absent 

1 Hartel: "Deutsch. Ztschft. f. Chir.," 98, 277. 

2 Rievel: "Knockenpathologie der Tiere." "Lubarschs and Ostertags Erge- 
buisse," xi, 1907. 



112 OCCURRENCE 

in the ten specimens examined, and in such we must attribute the 
cause either to intra-uterine pressure or to purely static causes arising 
late in life. That is to say, we must assume that the bones of the 
individual fowl possessed less than normal strength and yielded 
under weight. 

In quadrupeds, therefore, one finds as causes vertebral anomalies, 
inflammation of bones, and rickets. In fishes and snakes apparently 
the first named of these three causes, and in fowls vertebral anoma- 
lies alone, can be demonstrated as causes, leaving the bulk of the 
cases (ten out of twelve) to be accounted for as deformities due to 
weight acting on bones of less than normal resistance. Experiment- 
ally scoliosis has been produced in animals by Wullstein, Arndt, and 
Ribbert. 

FREQUENCY 

Figures with regard to the frequency of scoliosis in the population 
as a whole are lacking, except for some figures brought forward by 
Schanz. 1 In five years, of 189,000 recruits available for the German 
army 7.2 per thousand were disqualified for spinal curves of all kinds; 
that is, less than 1 per cent. Figures with regard to the percentage 
of scoliotics in hospital practice show nothing because the clientele of 
various hospitals varies so largely. Fortunately there are figures 
relating to its frequency in school children which are available, which 
form our only reliable means of judging its frequency. 

It is evident, however, that the percentage of scoliotics among a 
number of school children examined will vary with the point of view 
and standard of the observer, and this is shown by the very great dis- 
crepancy shown in the tables commonly quoted. These as a rule 
include old and new figures from all over the world from observers of 
every degree of special qualification. Such a table is given (Table V) . 

The very careful and modern investigations of Combe, Scholder 
and Weith, Gronberg, 2 Haglund, 3 and Lubinus 4 seem to form the 
safest basis for conclusions. According to these, the frequency in 
girls of the school age varies from 10 to 23 per cent, and of boys from 
16.4 to 26 per cent. 

It has been noted, however, that the percentage varies in different 
localities without obvious reasons, Gronberg finding in Abo a percent- 
age of 1 1.6, while in the neighboring Finnish city of Wiborg similar 

1 "Verhdl. d. Deutsch. Ges. f. orth. Chir.," 1910, page 454. 

2 "Ztsch. f. orth. Chir., xviii, 130. 

3 "Ztsch. f. orth. Chir.," xxv, 649- 

4 "Verhdl. d. Deutsch. Geo. f. orth. Chir.," 1910, 469. 



SEX 

Table Y 



n 3 



Bovs 



Girls 



Observer 



Place 



Xo. 



Scoliosis, 
per cent. 



No. 



Scoliosis, 
per cent. 



1864 Guillaune 

? Hiirliman 

1882 Mayer 

1885 Key 

1885 Drachmann 

1891 Wisser 

1892 Bardenheur and 

Castenholz. 

1893 Brunner, Klausner 

and Seydel. 

1894 Krug 

? Hagmann 

? Kallbach 

1901 Combe, Scholder and 
Weith. 

1906 Silfwerskiold 

1907 Gronberg 

1910 Haglund 

1910 Lubinus 



Merchatel. 

Gug 

Furth 

Sweden. . . 
Denmark. 
Wiirzburg. 
Cologne . . . 



350 



n, 210 0.8-5.7 

16,789 0.8 

280 5. 5 



Munich 1.052 6. 2 

569 

•• 695 



26 



Dresden 

Moscow 

St. Petersburg.. 

Lausanne j 1,290 23 



r 

336; 

3,072 

1,1386 

217, 

439 

987 
489 

723 
1,664 

2,333 
1,024 



Goteborg , 

Wiborg 4,257 11. 9 

Stockholm 819 13.2 

Kiel 1,021 10 



41 
22 

37 
10.8 

2 
45-6 

8.2 

6-5 
22.5 
29 
26 
26.7 



3,234 12.8 

4,093 22.1 

780 16.4 

2,204 18 



investigations by Gronberg showed 34.5 per cent, of scoliosis, and 
Lubinus found in Kiel in different girls' schools of the same grade that 
the percentage of scoliotics varied from 13. 1 to 34.6 per cent, without 
assignable cause. This has nothing to do with the variation accord- 



ing to age to be discussed later. 



SEX 



It is generally the opinion that in adults women show a greater 
number of scolioses than men, although published statistics confirm- 
ing this fact do not exist. Records of the relative frequency of sco- 
liosis in adolescents and children made in orthopedic institutions 
where patients apply for treatment show a very much larger percent- 
age of scolioses among girls than in boys. The difference between 
the sexes is less where large numbers of school children are investi- 
gated, such figures showing in general a slightly higher percentage in 
girls than in boys. To explain this difference we must either assume 
that boys outgrow scoliosis or that they do not come to the institu- 
tions for treatment until the curves become severe or until complica- 



114 OCCURRENCE 

tions arise, while in girls the effects of scoliosis upon the figure are 
perceptible much earlier, and treatment is sought to remedy curves 
which in boys would pass unnoticed by the parents. 

The table which follows shows the great preponderance of girls 
coming to institutions for treatment. The figures for the proportion 
of the sexes in school children are given in the table in the section 
on Frequency. 

Figures from Institutions where Patients are Treated 

Boys, Girls, Boys, Girls, 

per cent, per cent. per cent, per cent. 

Eulenburg 13 87 Adams 12.8 87 

Ever 7 93 Scholder . 14. 8 85 

Ketch 17 83 Schanz 25 74.8 

Kolliker 20 80 Rosenthal. 22 78 

Roth 8.5 91 • Schulthess 14.2 85.5 

Wedberger 15.9 84 Redard 15.6 83.3 

Behrend 13.4 86 

AGE 

Scoliosis is an affection of the years of growth in a large majority of 
cases, but it is often extremely difficult to form an accurate idea of 
the age at which the deformity begins in individual cases. Scoliosis 
due to rickets, infantile paralysis, and congenital causes may occur up 
to the fifth year. In general, however, the inaccurate observations of 
parents furnish no foundation upon which to base theories or statis- 
tics concerning the time of the beginning of the scolioses observed in 
older children. The relation of age to scoliosis as observed in the 
schools will be discussed later. 

In regard to the age at which scoliotic children are brought for 
treatment, Eulenburg found over 50 per cent, of all cases between 
seven and ten years old, and but 10 per cent, between the ages of 
ten and fourteen years. 

The clinical material collected by the Institute of Liining and 
Schulthess at Zurich has been used by Sutter and Miiller in preparing 
curves of the frequency of scoliosis at different ages. Miiller finds the 
greatest number of cases in the fourteenth year. The number 
increases gradually from the eighth to the fourteenth year, and 
decreases rapidly from the fourteenth to the seventeenth year. 
Sutter found that the number of boys brought for treatment reached 
the maximum in the ninth, thirteenth, and fourteenth years. The 
number of cases under treatment at fourteen years of age is double 



FRKQl I \CV OF DIFFKK F.XT FORMS II5 

that for nine years, and shows not only an increase in frequency of 
scoliosis, but an increase of deformity in curves already existing. 

RELATIVE FREQUENCY OF THE DIFFERENT FORMS OF SCOLIOSIS 

Statements concerning the frequency of the simple forms of scolio- 
sis are of very recent origin. All statistics agree, however, in show- 
ing that for all forms there are more scolioses convex to the left than 
to the right. There is less unanimity as to which of the single forms 
is the most frequent. Lorenz states that left lumbar scoliosis is the 
most numerous. Kolliker, from the examination of 721 cases, finds 
the simple dorsal scoliosis the most frequent. By considering the 
tables of other investigators Schulthess found the compound right 
dorsal scoliosis the most frequent form, followed in order by the 
simple dorsolumbar curves, total scoliosis, and lumbar scoliosis. 
The cervicodorsal form was the least frequent. 

Among the 571 school children with lateral curvature out of 2134 
children examined at Lausanne, 401, or 60.3 per cent., showed curves 
convex to the left, 121, or 21.1 per cent., curves convex to the right, 
and 49, or 8.6 per cent., compound curves. The table compiled 
from these figures shows the percentages of curves as to their form and 
convexity. The total curve is the most frequent form in school 
children, and is followed by the left and right lumbar curves and by 
left dorsal scoliosis. 

Total 
per cent. 



Left convex 


Right convex 




Total scoliosis.. . 48. 1 per cent. 


7 . 8 per cent. 


06 


Dorsal scoliosis.. 8.4 " 


4-3 " 


12.7 


Lumbar scoliosis. 11. 8 " 


8.5 " 


20.3 


Combined scoliosis. 8 . 5 per 


cent. 


8-5 



Almost the only records that have been studied and tabulated for 
definite study are those of the Institute of Liming and Schulthess, 
and it is from these investigations that much of the following mate- 
rial is drawn. 

Age. — At eight years the left scolioses form 64 per cent, and the 
right scolioses 33 per cent, of the total number of curves. In the 
fourteenth year the number of curves convex to the left and right is 
about equal. The number of compensating curves increases from 27 
per cent, in the eighth year to 45 per cent, in the seventeenth year. 

Position of Apex of Deviation. — To ascertain the location of the 
point of maximum deviation Durrer has constructed a set of curves 
which show that for the left convex scolioses the maximum deviation 



Il6 OCCURRENCE 

is at the dorsolumbar junction, and for the right convex curves the 
apices are found in the region of the seventh dorsal vertebra, which 
showed a much greater deviation than the adjacent vertebrae, while 
in the left convex curves the deviation is more evenly distributed 
over the length of the spine. 

Schulthess finds four principal apices of deviation for single and 
compound forms of scoliosis: (i) The upper dorsal region to the 
right; (2) the dorsolumbar junction to the left; (3) the upper dorsal 
and lower cervical regions to the left; (4) the lower lumbar region to 
the right. 

In the eighth year the maximum deviation of the right dorsal 
curves is in the region of the sixth to the eighth dorsal vertebrae, and 
is still found there in the seventh year. The apex of the left convex 
curves in the eighth, ninth, and tenth years is at the ninth or tenth 
dorsal vertebra; between the ages of eleven and thirteen it is found 
at the twelfth dorsal vertebra, and descends to the first or second 
lumbar vertebra between the ages of fifteen and eighteen years. 



CHAPTER X 
THE RELATION OF SCOLIOSIS TO SCHOOL LIFE 

The relation that school conditions bear to scoliosis is one of the 
most important questions in formulating the cause of scoliosis and 
has been much discussed of late. It is important to examine certain 
practical aspects of the question. 

School Fatigue. — A correct attitude is dependent upon the tone 
and strength of the muscles by which the upright posture is main- 
tained, so that any cause, such as fatigue, which lowers the muscular 
tone, has a bearing in this connection. 

Mental Fatigue. — Muscles become relaxed not alone by physical 
but by mental exertion and mental fatigue. 1 Mental work is at first 
stimulating, but if continued for a long time, especially concentrated 
on one topic, will produce both mental and bodily fatigue. 

Continuous mental labor, though of only short duration, will produce a greater 
degree of fatigue, and that more quickly, than the same amount of work inter- 
rupted by brief intervals of rest. A change of work, particularly from a hard to 
an easy subject, will afford the same relief as a short rest. Severe fatigue comes 
on with great regularity in periods of the ancient languages and mathematics, 
while recuperation takes place during history, geography, and nature, study. 
The modern languages occupy a middle place; singing and drawing make rather 
great demands on those who do well in these branches. After violent or pro- 
longed exercise one is less fit for study, but after moderate exercise intellectual 
work seems to become easier. The proper relation between physical and intel- 
lectual work, in order to obtain the greatest good from each, is a question which 
should receive the careful consideration of educators. 

Exhaustion in Children. — One of the first ways in which fatigue shows itself is 
in the slight amount of force expended in a movement and frequently a lessening 
in the number of movements. In extreme exhaustion the ordinary movements 
are not excited by ordinary stimuli, and such as do occur are slow and labored. 
This may be accompanied by irritability and occasional jerky movements not con- 
trolled by circumstances. Frequently there is manifest an asymmetry of posture 
and movement. The head is held on one side; the arms when extended are 
not horizontal — usually the left one is lower; the hand balance is weak; that is, 

1 Kronecker: "Ueber die Ermiidung und Erholung der gest. Muskeln," 
Leipzig, 1871; Mosso: "Fatigue," "International Science Series," Sikorsky: 
"Sur les effets de la Lassitude provoquee par les travaux intellectuels chez les 
enfants de Page scolaire;" Leo Burgerstein: "Die Arbeitskurve einer Schul* 
stunde;" Hugo Laser: "Ueber geistige Ermiidung beim Schulunterrichte." 

117 



Il8 SCHOOL LIFE AND SCOLIOSIS 

when hands and arms are held straight out in front, the fingers and wrists are 
not extended, and the thumb is not on the same plane as the fingers; this also is 
more marked in the left hand. Lack of muscular tone shows itself in a "slumped" 
position either standing or sitting. The face may be lengthened from relaxation 
of the muscles and falling of the jaw. Sighing and yawning are common 
symptoms. Speech is slow, and the tone of the voice altered, and in general there 
are slowness and inaccuracy of mental response. 1 

School Furniture. — It is obviously important to furnish school 
children with seats and desks which do not favor improper attitudes 
in sitting and writing. 2 In 1842 Barnard, of Hartford, published an 
article on the subject, followed twenty years later by Fahrner, 3 of 
Zurich, Myer, 4 Cohn, 5 Schenk, Lorenz, 6 Schulthess, 7 and Scholder; 8 
and a most practical study of the matter was undertaken by the 
Boston Schoolhouse Commission. 9 

The two things to be prevented in school furniture are — (a) the 
prolonged stretching of the back muscles by the continued mainte- 
nance of flexion of the spine, and (b) the assumption of distorted and 
twisted attitudes, children with tired muscles tending to rest them by 
assuming a change of position. Furniture of bad design or improperly 
fitted tends to favor both of these. 10 A large number of desks and 
seats have been devised; it is said that 150 have been proposed, and 
at least over 30 have been tried. The theoretical requirements which 
are by common consent accepted are as follows: 

1. The height of the seat from the floor should be such that in sit- 
ting the feet rest on the floor. Too high a seat produces pressure 
on the back of the thighs; too low a seat induces too much flexion of 
the lumbar spine. 

2. The slope of the seat should be backward and downward about 
three-eighths of an inch. The depth of the seat should be about two- 
thirds the length of the thighs. The width of the seat should be that 
of the buttocks. Some concaving of the seat is comfortable, but not 
essential. 

3. The back of the seat should have a slope backward of one in 

twelve from the vertical line (Saxon regulations). The more modern 

1 Warner: "The Nervous System of the Child," London, 1900.^ 
2 Scudder: "Determination of the Muscular Strength in Growing Girls," 
"Bos. Med. and Surg. Jour.," Nov. 6, 1890. 

3 "Das Kind u. d.Schultisch," 1865. 

4 "Die Mech. des Sitzens," "Virch. Arch. f. path. Anat.," xxxv, 1867. 

5 "Beitr. zur Losung der Subsellenfrage," Berlin, 1885. 

6 Lorenz: "Ueber die Skol,." Wien. 

7 Schulthess: "Zeitsch. f. orth. Chir.," 1892, i, 1. 

8 "Archiv fur Orth.," i, 2. 

9 Boston Schoolhouse Commission Reports for 1901-5. 
10 Feiss: "Cleveland Med. Jour./' Aug., 1905. 



WRITING POSITION' 



II 9 



expression of this is found in two back supports, one low down, one- 
half to one inch in front of the back edge of the seat, and a second 
higher up, one and one-half inches behind the back edge of the seat. 
But in a nearly balanced sitting position a relatively low back support 
is ample and the upper one not required. 

4. The height of the desk should be such that the back edge allows 
the forearm to rest on it naturally with the elbow at the side. The 
height of this edge from the edge of the seat is known technically as 
the ''difference." 

5. The slope of the desk has been advocated at all angles from o to 
45 degrees. The theoretically best slope for reading is at least 30 
degrees, but this is practically 

too steep and books slide off, 
and it is not practicable for 
writing. From 10 to 15 de- 
grees is the usually accepted 
inclination. The proper dis- 
tance of the eyes from the 
desk is from 12 to 14 inches. 
The width of the desk is im- 
material, 22 to 24 inches being 
the usual size. 

Writing Position. — Of late 
years there has been a ten- 
dency to blame the teaching 




Fig. 



>S- — Boston School Desk and Chair 

—{Boston Schoolhouse Commission.) t 



of slanted handwriting for 

much of the bad attitude and 

the teaching of vertical writing was substituted, the patient sitting 

squarely in front of the desk and writing vertically, with a view of 

avoiding the distorted position incidental to slanted handwriting. 

Statistics have been reported in favor of the vertical system. These 

are: 

Percentage of Scoliotics 

In Slanted Writing In Vertical Writing 

Nuremburg 24 15 

Zurich 32 12 

Munich 24 15 

Fiirth 65 31 

Wurzburg 28 8 

The question is by no means settled, Gould, of Philadelphia, having 
called attention to certain factors previously overlooked. 



120 



SCHOOL LIFE AND SCOLIOSIS 



" With 1 the head and body erect, the paper straight before the me- 
dian line of the body, and the penholder held as commanded, no per- 
son can or will write, for the simple reason that the writing and the 
writing field about the pen-point are hidden by the writing hand and 
the penholder. Immediately the pupil skews the paper, tilts the 
head to the left, and grasps the holder differently — all in order to 
bring the writing field and letters being made into clear view, and 
especially of the right or dominant eye. 




Fig. 86. — The Hand in the Writing Posture as Usually Ordered, but not Prac- 
tised, Because to the Writer the Writing Field is Hidden by the Thumb, Finger, 
and Holder. — -(Gould.) 

A view of the hand, as seen by the writer, with the head displaced in photographing. 



" The slanted handwriting is due merely to the fact that less torsion 
or rotation of the head to the right is rendered necessary, and a slight 
easing is secured by slanting the letters to the right. 

It may be assumed as reasonable (i) that bad air, fatigue and 
school life under poor general conditions, (2) improper school furni- 
ture, and (3) twisted writing positions favor bad attitude, and that 
the more constantly they are in operation the more effective will be 
their result in producing bad attitude. In the same way unfavorable 

1 G. M. Gould: "American Medicine," ix, 14, 562, 1905. 



INCREASES DURING SCHOOL 121 

home conditions in the way of bad food, overwork, and unsanitary 
surroundings depreciate muscular strength and favor bad attitudes. 

It is therefore likely on general principles that unfavorable school 
conditions are a competent cause of faulty attitude (false scoliosis) 
and of slight grades of true scoliosis, but that they are the cause of 
moderate and severe scoliosis is not, in the writer's opinion, likely. 
The reasons for this view have been expressed at the beginning of the 
chapter on Occurrence. 

This view is in accord with that of the best modern authorities, 1 
but not in accord with former views. 2 

It is therefore necessary to investigate existing data with regard to 
the occurrence of scoliosis in school life to see what evidence is to 
be found in them. 

There are practically no figures dealing with the question in 
America and it must be remembered that figures from foreign sources, 
although probably applying to our conditions, cannot be unreserv- 
edly accepted. It has already been shown that there may be a great 
variation in the percentage of scoliosis in the school children of two 
neighboring cities and between children of different schools in the 
same city (see Occurrence, page 113). 

Increase of Scoliosis during School Life. — When careful statistics 
are taken among school children they show most often, but not uni- 
formly, a larger proportion of children affected with scoliosis in the 
later than in the earlier years of school. 

Haglund's studies 3 were especially careful and show an increase 
with school age as follows: 

Year 6 7 8 9 10 11 12 13 14 15 1599 cases. 

Per cent, scoliosis. 11 13 18 16 18 24 22 22 .. 283 scolioses. 

Gronberg, from a careful study of 8350 school children in Finland, 
concluded that "the frequency of scoliosis increases as age increases 
and as the classes become higher. Constancy of progression is not, 
however, always to be found." 

His tables were as follows: 



Year, 


11 


12 


13 


14 


15 


Grammar schools. . . 


12.2 


15-6 


12.5 


n-3 


16. 1 


Higher schools 


/ 9-4 
\ 26.1 


7-3 

32.7 


8.8 
26.9 


9.9 

44-4 


12.4 
40.3 



Boys. 

1 ''Verhdlungen d. Deutsch. Ges. f. orth Chir.," 1910, pages 443-514. Schult- 
hess, Schanz, Mayer, Spitzy, Bohm, Muskat, Lubinus and others. 

2 Smith: "Lat. Curv. of the Spine and Flat-foot," New York, 191 1, page 28. 

3 "Zeitsch. f. orth. Chir.," xxvi, 649. 



122 SCHOOL LIFE AND SCOLIOSIS 



Year, 


ii 


12 


13 


14 


IS 


16 


Grammar schools. . 


21.2 


18. 1 


19. 1 


23-3 


26.5 


21 .9 


Higher schools 


f 16.9 

' I 48.1 


18.9 
49.0 


21-5 

49.6 


20.9 
59-8 


22.3 
63.2 


24.7 
56.8 



Girls. 



The figures as to the increase of scoliosis during school life from 
2314 cases examined at Lausanne are as follows: 1 

Age Boys Girls 

8 years 7.8 per cent. 9 . 7 per cent. 

9 " 16.7 " 20. 1 

10 " 18.3 " 21.8 

11 " 24.2 " 30.8 

12 " 27. 1 " 30. 2 

13 " 26.3 " 37.7 

On the other hand, certain observers have found the contrary. 
Spitzy 2 for ten years has examined about too girls from eight to six- 
teen years old each year in a large private school for girls in Graz and 
finds a constant percentage each year of about 20 per cent, of marked 
defects of position, and this percentage is not greater in children 
who have previously been to school than in those educated at home. 
Hippius 3 has demonstrated that severe scoliosis is frequent in children 
who have never been to school. 

Kirsch 4 in 1000 school children from the lower classes and 1000 from 
the more advanced classes investigated since 1906 found that "the 
greatest number of all fixed scolioses, which we find in school, are 
rachitic scolioses from early childhood." 

In 3234 girls, Silfwerskiold found percentages as follows: 

First class, 10. o per cent. 

Second class, 12. 1 " 

Third class, 12.5 " 

Fourth class, 17.0 " 
Fifth class, 9.9 " 

Forms of Scoliosis in School Children. — "So far as the forms of 
scoliosis which are most frequent in children, they are in a certain 
way peculiar and vary from the forms most frequently coming to 
specialists for treatment." 5 

Of these curves only 24 per cent, were compound in Gronberg's 
series and the remainder were simple, 41.9 per cent, being left total 

1 Combe, Scholder and Weith: "Jahrb. der Schu. Gesel. f. Schulgesundheits 
pflege," ii, Jahrg., 1901, i, Teil, 38. 

2 ''Verhdl. d. Deutsch. Ges. f. orth. Chir.," 1910, page 462. 

3 "Der kinderarzt als Erzieher," Berk, Munchen. 

4 "Verhdl. d. Deutsch. Ges. f. orth. Chir.," 19 10, 94. 

5 Gronberg: "Zeitsch f. orth. Chir.," xviii. 156. 



CONCLUSION 123 

curves. In the Lausanne series 48.1 per cent, were left total curves 
and only 8 per cent, of the whole were compound scoliosis. 

The conclusion from which, is that apparently if one takes into 
account all grades of scoliosis, functional and structural (false and 
true), there is a tendency to increase during school years, but there 
apparently is no good evidence that moderate and severe structural 
scolioses increase during school life or are directly caused by it. 



CHAPTER XI 

DIAGNOSIS 

Scoliosis is an affection in most cases appearing before the tenth 
year; it is not a disease of the spine, but the result of mechanical 
forces acting upon a spine which in other than slight cases must be 
assumed for some reason to be abnormally formed or to possess less 
than normal resistance. It is not, as a rule, accompanied by any 
degree of pain. Stiffness, if it is present, is an accompaniment of 
late cases and the result of long-continued structural changes. 

In the diagnosis of scoliosis the first question that arises is whether 
or not scoliosis is present. A plumb-line is held in the line separat- 
ing the buttocks, and if all the spinous processes lie under that line 
scoliosis is not present. If any number of spinous processes do 
not lie under the plumb-line scoliosis is present. 

If scoliosis is present the question is, is it functional or structural, 
and what is the curve? The diagnostic signs of functional and struc- 
tural curves have been described (pages 55, 61, and by aid of these 
the curve is classed as one or the other or as transitional (page 57). 
The ends of the spine are connected by a string and the parts lying 
to the right are called right curves and those to the left are called 
left curves. 

If the curve is Junctional, it is desirable if possible to identify its 
cause in a short leg, unequal vision, etc. 

If the curve is structural it is important, if possible, to assign it to 
its proper etiological division. 

Scoliosis of Congenital Origin. — Such curves occur early, are gen- 
erally severe, and are best identified by the x-ray. When accom- 
panied by gross defects in the thorax or elsewhere they are easily 
recognized. 

Rachitic Scoliosis. — This form occurs early, is generally severe and 
characterized by a sharp curve, and most often found in the lower 
half of the spine. To establish the diagnosis, other signs of rickets 
should be found. These are the high square head, the rosary, 
curved bones, enlarged epiphyses and usually somewhat retarded 
general growth. A history of a late first dentition suggests the 

124 






DIAGNOSIS 125 

existence of rickets. Osteomalacia is uncommon and characterized 
by severe general curvature of the bones. 

Infantile Paralysis. — This is a motor paralysis beginning with a 
feverish attack, generally in summer, followed by loss of power in one 
or more limbs. The affected limbs are in the severer cases cold and 
wasted and reflexes are lost. In the severer cases of scoliosis of this 
type the deformity becomes extreme. There are occasional cases of 
infantile paralysis where the attack is slight and the loss of motion is 
apparently recovered from, but where a lateral curve of more or less 
severity develops later as a result of the paralysis of some spinal mus- 
cles. The investigation into the history in doubtful cases becomes of 
much importance and the back should be examined in every case of 
infantile paralysis in any part of the body. 

Empyema and pleurisy are recognized as the causes of a severe 
form of scoliosis, especially when a resection of the rib has been per- 
formed in empyema. The curve is always convex toward the unaf- 
fected side of the chest and is dorsal or dorsolumbar. It is identified 
by the scar on the chest or the auscultation signs in the thorax and 
the history of the case. Any other scar of sufficient size is competent 
to produce the same result. 

Other evident causes of structural scoliosis are sufficiently indi- 
cated in the table given in the chapter on Etiology. 

Finally, in many cases no evident cause can be found and one is 
obliged to assume that the bones of the individual possess less than 
normal resistance to weight bearing. 

Pathological Conditions Accompanied by Lateral Curvature as a 
Symptom. — Cases of lateral curvature accompanied by pain, espe- 
cially if this is exaggerated by motion, should not be given exercises, 
but kept under careful observation until a perfectly definite diagnosis 
has been made. The same applies to slight curves accompanied by 
stiffness of the spine. Doubtful cases may often be cleared up by the 
use of the x-ray. 

These painful conditions accompanied by scoliosis must be care- 
fully separated from true scoliosis. The chief one of these is Potfs 
disease, or tuberculosis of the spine. The symptoms of this affection 
are stiffness of gait and loss of mobility in the spine, pain on motion or 
jar, and spontaneous pain in the chest and abdomen, elevation of 
temperature, and impairment of the general condition. As the 
disease progresses, a sharp prominence backward of the spinous proc- 
esses occurs at some part of the spine. Lateral deviation of the 
spine occurs in the acute stage of practically all cases, but it is a 



126 DIAGNOSIS 

leaning of the body to one side rather than a true gradual curve; 
there is no rotation of note, and the lateral deviation is an index of 
the severity of the disease, disappearing after a period of recumbency 
in bed and being controlled by efficient treatment. The danger of 
mistaking Pott's disease for scoliosis lies in the early cases before the 
knuckle, or backward deformity, has occurred. 

A form of lateral deviation accompanies arthritis deformans of the 
spine, which is also known under the names of osteoarthritis of the 
spine, spondylitis deformans, ankylosis of the spine, spondylose 
rhizomelique, Bechterew's disease, Steifigkeit der Wirbelsaule, etc. 
This is essentially an affection of adult life, but not unknown in 
children. The spine is stiff and painful, the lumbar convexity is 
diminished or lost, and the carve a gradual one with slight or no 
rotation. 

The lateral curves accompanying tumors of the spine, dislocation 
of the vertebrae, etc., would hardly be mistaken for real scoliosis, the 
usual signs of those affections being present. 



CHAPTER XII 

PROGNOSIS 

WITHOUT TREATMENT 

Total curves may remain as such through life, probably increasing 
somewhat; they may change to structural curves; or they may be 
cured by proper treatment, but they are not likely to disappear 
spontaneously. So long as they remain purely functional curves, 
as defined above, they will probably not influence the general health 
unfavorably or produce any unpleasant result further than slight 
asymmetry. In neurasthenic women they are frequently accom- 
panied by backache. 

Structural curves, whether simple or compound, in young children 
should be regarded as serious, as almost sure to increase, and perhaps 
to increase rapidly. They will surely lead to some deformity, and 
perhaps to grave deformity. They are likely to affect the general 
health and to shorten life by inducing phthisis and ill health. Adults 
with severe scoliosis are, as a rule, less vigorous than normal. 

Slight or moderate structural curves in older children and adoles- 
cents which have not progressed rapidly through childhood are after 
puberty likely to increase but slowly, if at all, until late middle life, 
when the atrophy of the intervertebral discs is likely to make them 
more evident and troublesome. Severe structural scoliosis at any 
period of life is to be regarded as likely to shorten the patient's life 
and to induce ill health. The rapid increase of a postural or struc- 
tural curve is a threatening symptom demanding attention. 

WITH TREATMENT 

Total scoliosis should be entirely and permanently cured by 
adequate treatment. 

Structural scoliosis in young children when of moderate degree 
should be practically cured by adequate and long-continued treatment 
but only by that. If severe, it should be much improved by the 
same means, the prognosis in both classes being better in children 
with a long period of growth ahead than in adolescents. 

127 



128 PROGNOSIS 

Structural curves in older children and adolescents when of moder- 
ate degree should be greatly improved by adequate and long-continued 
treatment, but as a rule cannot be wholly cured. Severe structural 
scoliosis under these conditions can be markedly improved. 

When growth has been reached, only improvement and not com- 
plete cure is to be hoped for from treatment in true scoliosis of any 
but the mildest grade. In adults with severe scoliosis the general 
condition of the patient may be greatly improved by an improved 
position of the spine. In late adult life support of the spine in the 
best obtainable position is the only outlook from treatment, again 
often attended by improvement of the general health. 

Scoliosis due to severe congenital defects of the vertebrae, scapulae, 
or thorax, to infantile paralysis, or to empyema cannot be cured if a 
curve of moderate or severe grade has occurred, but can be improved. 
Rickets contributes a class of cases on the whole resistant to treat- 
ment, and in severe cases, even in young children, a complete cure 
is probably not obtainable. The existence of organic heart disease 
or phthisis makes the prospect of obtaining much improvement 
from treatment unfavorable. 



CHAPTER XIII 
TREATMENT 

The treatment of scoliosis can be most clearly considered if one 
separates for purposes of discussion the two types of cases already de- 
scribed (pages 55-61) — (1) the postural or functional, and (2) the 
organic or structural. That such a distinction is not always sharply 
to be made, that transition cases are to be seen, and that many 
therapeutic measures are common to both classes of cases, applies 
here as in most other departments of medicine and surgery where 
functional and organic conditions are separated. 

To call both of these varieties by one name, scoliosis, leads to 
confusion and contradiction, to widely differing statements as to 
etiology, and to marked divergence of views with regard to treat- 
ment and its results. If we grouped together all sprains and joint 
fractures under the term of "fractures" without regard to the 
presence or absence of bone injury, our classification and our treat- 
ment of these injuries would become confused, contradictory, and 
unsatisfactory. 

It is clearer to designate as "false" scoliosis the postural variety, 
and as "true" scoliosis the structural variety, so that in the con- 
sideration of etiology and treatment we may not be grouping under 
one name two conditions essentially different. 

True scoliosis constitutes our real problem, of course, but in order 
to make that part of the subject perfectly clear, we must first dis- 
cuss and remove from our field the less important question of false 
scoliosis. 

THE TREATMENT OF POSTURAL SCOLIOSIS (FUNC- 
TIONAL SCOLIOSIS, FALSE SCOLIOSIS) 

Regarding the condition as an habitual inability to stand correctly, 
as a postural malposition without marked structural change, it is 
evident that the treatment should consist in the substitution of a 
correct attitude for the faulty one. This is obviously to be preceded 
by eliminating conditions unfavorable to the maintenance of a correct 
9 129 



130 TREATMENT 

upright position. The conditions requiring investigation and pos- 
sible correction in every case as a preliminary to beginning treat- 
ment are — (1) seats and desks at school; (2) the manner of clothing 
the child; (3) the condition of the eyes and ears; (4) the existence 
of a short leg; (5) overwork or too long hours, leading to persistent 
fatigue; (6) excessive recent growth with consequent impairment of 
resistance. These matters are also of importance in structural 
lateral curvature. Having placed the patient under the most 
favorable conditions obtainable and having corrected so far as 
possible the defects above mentioned, the patient should work on 
the exercises to be described for from half an hour to two hours a 
day for a period of some weeks, which exercises should not be 
pushed beyond the limit of fatigue. 

After a period of vigorous daily work under the direct supervision 
of the surgeon, which should generally be continued for two or three 
weeks, home work under the direction of the parents may be sub- 
stituted for it, with occasional supervision by the surgeon at longer 
and longer intervals. But it is desirable that such patients should 
be under observation for at least a year. 

The length of treatment, the period of the exercises, and the extent 
to which they can be pushed will depend on the vigor of the child, 
as half-way measures are not likely to be successful and exercises 
done at home under the supervision of careless parents are less effi- 
cient than those given by persons trained in the art of gymnastics. 
The treatment lies within the range of any good teacher of gymnastics 
who will carry out the instructions of the surgeon. The causes of 
failure are to be found in the fact that such children are generally 
in poor muscular condition and are often overworked at school or 
under unfavorable conditions at home, or that the exercises are given 
too seldom and are not sufficiently vigorous. 

If flexibility to one side is limited, i.e., if the child can bend further to 
the right than to the left in a left total curve, the flexibility of the spine 
must be made equal, preferably by means of passive lateral stretch- 
ing in the apparatus, described on page 156, or by means of gymnas- 
tic exercises. Having restored the flexibility of the spine by this 
means or if flexibility to the two sides is alike, a treatment differing 
but little from the " setting-up drill" of the army recruit is to be 
instituted. Exercises suitable for the treatment of postural cases 
will be described in connection with the gymnastic treatment of 
structural scoliosis. 



TREATMENT 131 

TREATMENT OF STRUCTURAL SCOLIOSIS (ORGANIC 

SCOLIOSIS, HABITUAL SCOLIOSIS, FIXED 

SCOLIOSIS, TRUE SCOLIOSIS) 

The problem to be met in the treatment of lateral curvature with 
fixed bony changes is a perfectly definite one. A clear understanding 
of the obstacles to be met and of the means at our disposal for meet- 
ing them is essential to successful treatment. 

The spinal column having curved to one side has, in the course of 
time, become fixed in the deformed position. In addition to the side 
curve, a rotation or twist in the length of the column has occurred at 
the seat of the main and compensatory lateral curves, particularly 
evident in the thorax. As the result of the maintenance of the 
vicious position over a long time, covering part of the period of 
growth, changes in bones, muscles, ligaments, and intervertebral 
discs have occurred. The individual vertebrae have become com- 
pressed on one side and twisted by the rotation. The ligaments and 
muscles have become adaptively shortened on one side and stretched 
on the other, and the intervertebral discs to a greater or less extent 
have become compressed on the con-cave side of the curve. The 
region of the vertebral column involved by the curve has lost its 
normal mobility and is partly or wholly stiff. There are secondary 
changes in the thorax and abdomen and in the contained organs. 

It is obvious that in the upright position gravity works to increase 
the deformity by exerting pressure upon the concavity of the curves 
already atrophied by an abnormal weight bearing. Of the twenty- 
four hours in each day only some ten or twelve at most are spent in 
recumbency. During the remaining twelve or fourteen hours the 
vertical position is assumed and gravity is at work. 

The treatment of structural lateral curvature presents, therefore, 
a much more serious and much less encouraging problem than the 
treatment of postural cases, and measures must be vigorous, ade 
quate and surgically sound to produce a permanently satisfactory 
result. 

The causes of failure of efficient treatment lie in the unwillingness 
of the parents or the patient to submit to sufficiently long-continued 
and effective treatment to remedy a condition which, on the slightest 
consideration, can be seen to be one which is necessarily difficult and 
resistant. 

It is evident, where the pathological changes have reached a 
moderate degree, that considerable and continuous force would on 



132 TREATMENT 

general principles be necessary to force the column into a position 
approximately normal and also that on the forcing into and holding 
in such a position depends our sole hope of any considerable degree of 
favorable progress, progress necessarily due to the adaptive nature 
of growing bone — and to the fact that in its growth it will follow the 
lines of least resistance. The practical question is: how far may we 
depend on gymnastic treatment alone to accomplish this? Because 
gymnastic treatment is the traditional one for scoliosis, and is being 
pursued in this country to-day in the great bulk of all cases which are 
treated at all. 

GYMNASTICS 

Gymnastics have a two-fold object — first, to loosen up the curved 
portion of the spine to make an improved position possible, and, sec- 
ond, to aid in retaining the improved position by strengthening 
certain groups of muscles. Most exercises tend in a measure to 
accomplish both of these, so that a sharp division into mobilizing 
and. retentive exercises is not possible, and one can only point out 
that a certain exercise is especially valuable for one or the other 
purpose. 

It is essential to define and limit what place gymnastics should 
occupy in the treatment of structural scoliosis. It is obviously un- 
reasonable to expect free standing gymnastic exercises alone to 
straighten marked or severe curves or to change the shape of dis- 
torted bones. But after the greatest possible improvement has been 
secured in such curves by more efficient measures one must look to 
gymnastics to develop the muscles which will hold the improved 
position and make the gain permanent after the corrective jacket 
has been gradually discontinued. In marked and severe structural 
scoliosis, therefore, gymnastic treatment finds its use as supplemen- 
tary to forcible correction. 

The purely gymnastic treatment of severe structural scoliosis is 
to-day being largely pursued by two classes of persons. First, by 
irresponsible masseurs and medical gymnasts who hold as a tradition 
that gymnastic exercises are curative or at least helpful in scoliosis, 
and second, by surgeons who do not believe in corsets or supports. 1 
The former class serves only to bring the legitimate use of gymnastics 
for scoliosis into disrepute; the latter class use the gymnastics more 
or less effectively, and take a pessimistic view of the results to be 

iTeschner: "N. Y. Med. Rec," Dec. 6, 1903; Erich: "N. Y. Med. Jour.," 
Oct. 7, 1899. 



GYMNASTICS 



133 



obtained in severe scoliosis. Structural scoliosis is a bone problem; 
a glance at the deformed column indicates that, but it has been too 
largely considered and treated as a muscle problem. Until recently 
the treatment has been an indirect, intermittent, and long-continued 
effort to remedy a bony deformity by muscular meang. A surgeon 
would be thought very much behind the times who to-day endeav- 
ored to correct bony knock-knee or 
congenital club-foot by muscular 
exercise, yet many an up-to-date 
surgeon does not hesitate to advo- 
cate gymnastic exercise as the sole 
treatment of a bony deformity 
equally severe. The excuse for 





Fig. 87. — Patient with Left Dor- 
sal Curve in 1900. 



Fig. 88. — Same Patient in 1905 
after Five Years of Gymnastic 
Treatment. 



the use of gymnastic treatment under these conditions would be the 
fact that the results obtained by it were so very satisfactory that 
the practical outcome justified us in disregarding sound theory. 
But proof is wanting that this is the case. 

Gymnastic treatment in apparatus is, however, advocated as the 
sole treatment for all cases by such an eminent authority as Schul- 
thess, 1 and treatment by gymnastics and braces by an authority of 

1 JoachimthaFs Handbuch d. orth. Chir., Bd. iii, iv und v, page 1035. 



134 TREATMENT 

such great weight as Lange, 1 but neither of these men has published, 
nor apparently has claimed, such results as claimed and published 
by Wullstein, 2 Schanz, 3 Sever, 4 Abbott, 5 Lovett 6 and others. Nor 
can the author find the publication elsewhere of results from gym- 
nastic treatm«ut which are convincing as to the efficiency of the 
treatment in moderate and severe cases. Still, one must not pass 
too lightly over the opinions of such weighty authorities as Schulthess 
and Lange, and must allow due weight to them. 

If one makes no distinction between false and true scoliosis, and 
classes every lateral deviation of the spine as scoliosis, if he thus 
groups false and true scoliosis together and treats all cases by effect- 
ive gymnastics, the proportion of successful results will be large 
because of the predominance of the milder cases in almost any group. 
But if one uses the gymnastic treatment in a group composed wholly 
of moderate and severe cases of structural scoliosis, the results will 
be widely different from those of the first group. In this failure to 
separate the two varieties much of the contradictory evidence with 
regard to the results of treatment has arisen. Many well informed 
surgeons are deterred from the use of corrective jackets by the fear 
of inducing muscular atrophy of the back. But muscular atrophy 
of the back is quickly recovered from and the deformity is a grave 
one demanding measures which strike at the salient feature — the 
bony deformity. The history of the treatment of moderate and 
severe structural scoliosis as a muscle problem is a history largely of 
failure or of extravagant and unwarranted claims. 

Not only may gymnastics in moderate and severe structural 
scoliosis fail to do good, but they frequently do serious harm for the 
following reason : scoliosis of this grade soon results in a stiffening of 
the affected region of the spine. If efficient gymnastics are given, 
the spine is speedily rendered more flexible and if it is so rendered and 
not supported at once, it will sink into a worse position than before 
and the curve will be increased. The assumption made by the advo- 
cates of gymnastics is that the back muscles will be so developed by 
the exercises that they will immediately hold the spine in an im- 
proved position, but this does not happen,. and the flexibility in- 

1 Lange and Spitzy: "Handbuch f. Khde., Leipzig," 1910, Bd. v, page 140. 

2 Wullstein: "Zeitsch. f. orth. Chir.," 1902, Bd. x, Teil ii. 

3 Schanz: "Zeitsch. f. orth. Chir.," 1908, Bd. xxii, page 57. 

4 Sever: "Surgery, Gynecology and Obstetrics," September, 191 2. 

5 Abbott: "New York Med. Jour.," June 24, 1911, and April 27, 1912, 

6 Lovett: "Boston Med. and Surg. Jour.," October 31, 1901, March 17, 1904; 
"Jour. A. M. A.," June 23, 1906; Lovett and Sever: "Jour. A. M. A.," September 
2, 1911. 



GYMNASTICS 



135 



creases much faster than does the holding power of the muscles. 
Much harm would be avoided in the gymnastic treatment of these 
cases if this practical fact were recognized. 1 

Place of Pure Gymnastic Treatment. — In mild structural scoliosis 
efficient gymnastics should constitute the sole treatment, and may 
be continued as the sole treatment so long as the improvement from 
one exercise period persists until the next one. If such improvement 
is not held between exercises it must be assumed — (1) that the 




\ Mm SMmmgmm ^W^ m J 




<^LV? 


■0 ' ;,. ''^^Bf \ ^BST 1 


\ 


? 


r-f 






' W M m W 


L " ' 


MM 
mm BH| 


t 

t 


3^1 Ik 





Fig. 89. — Trunk Bending Ap- 
paratus. — (Schulthess.) 



Fig. 90. — Shoulder Pushing Apparatus. 
— {Schulthess.) 



exercises are not good ones; (2) that they are not properly carried 
out; (3) that the amount of treatment is insufficient, or (4) that 
the case is too severe for purely gymnastic treatment. Progressive 
improvement must be assumed as the criterion of efficient gymnastic 
treatment. 

It is impossible to draw a general line either theoretically, or in 
practice at the outset between cases of structural scoliosis which are 
likely to be cured by gymnastics alone and those which are not. 

^hlumsky: "Verhdlg. d. Deutsch. Ges. f. orth. Chir.," 1908, 317. 



136 



TREATMENT 



The line comes somewhere between the mild and the moderate cases 
and doubtful cases should be tried on the purely gymnastic treat- 
ment and kept on it only so long as they progressively improve. 
In other words mild cases are generally suitable for gymnastic treat- 
ment. Cases of moderate grade with slight rotation and not much 
lateral curve are also to be started on gymnastic treatment for trial, 
cases of moderate grade with marked rotation and curve are not 
suitable for gymnastic treatment alone and all cases of severe scoliosis 
are unsuited to gymnastic treatment. 




Fig. 91'. — Hip-pendulum and Shoulder- raising Apparatus. — (Schulihess.) 

Scheme of Treatment. — (1) Gymnastics may be given alone as a 
treatment, or (2) in cases where the patient becomes rapidly flexible 
or seems to require support between exercises, such treatment may be 
supplemented by the use of supporting jackets, braces or corsets. 
(3) In connection with gymnastic treatment intermittent passive 
stretching may be useful in restoring flexibility or (4) both corsets 
and stretching may find their use in connection with gymnastics. (5) 
Finally forcible correction should constitute the treatment of most 
moderate and all severe cases. 



GYMNASTICS IN APPARATUS 137 

The use of braces and corsets alone cannot be considered a treat- 
ment for scoliosis. To make this matter plain the following scheme 
presents the above statements in the form of a table: 

W Gymnastics alone { $ JSffi^aratus. 

(2) Gymnastics and corsets. 

(3) Gymnastics and stretching. 

(4) Gymnastics and corsets and stretching. 

(5) Forcible correction. 

i (a). Gymnastics Given in Apparatus. — By means of apparatus 
gymnastic exercises can be very much more correctly localized, and 
the work of loosening the spine and of strengthening the desired 
muscles can go hand in hand. This method, which is in general use 
in Europe, has never found a foothold in this country on account of 
the complicated and expensive apparatus. 

The system of apparatus devised by Schulthess and its modifica- 
tions, the apparatus of Zander, and the simpler apparatus of Lange, 
are the best examples of the kind. 

The precision of the apparatus, its adaptation to anatomical needs, 
and the principle of securing correction and the development of 
desired muscles at the same time make the system sound and efficient. 

i(b). Gymnastic Exercises Given Without Apparatus. — This 
method of treatment is the one in most general use in America. It 
is open to the objection that the force exerted is not sufficiently 
localized, but is distributed over the spine. 

Fixation of Pelvis. — It is essential that the pelvis should be fixed 
during such exercises, as otherwise the pelvis is displaced and the 
movement becomes a general and not a local one. A simple wooden 
apparatus may be constructed which holds the pelvis and does away 
with the necessity of holding the hips of the patient between the 
knees, which must otherwise be done. This saves labor on the part of 
the person giving the exercises, and permits a closer supervision of the 
back than is possible w r hen part of the attention must be fixed on 
holding the patient firmly. 

The apparatus, which was suggested by that of Bade, 1 consists of a 
wooden clamp made by two flat boards set at right angles to a hori- 
zontal board on which they slide to hold the sides of a pelvis of any 
width. The whole apparatus moves up and down on an upright 
fastened to a large round floor platform and may be inclined at any 
angle to the horizontal plane. The patient is secured in place by 
sliding in and fastening the lateral clamps at the sides of the pelvis, 

1 "Zeitsch. f. orth. Chir.," xii, 4, 799. 



i38 



TREATMENT 



and by securing the front of the pelvis by a broad leather strap pass- 
ing from one arm to the other. The floor platform is so large that 
the apparatus cannot upset (Fig. 94). 

General Routine and Precautions.- — It is desirable that the back 
should be exposed during the exercises in order to note the effect of 





Fig. 92.— Composite Photograph (Two 
Exposures on the Same Plate) Show- 
ing the Model Standing Erect and 
Bending to the Right without Fixa- 
tion of the Pelvis. The Movement 
is a General One. 



Fig. 93. — Composite Photograph of 
the Model Standing Erect and Bend- 
ing to the Right with the Pelvis 
Fixed. The Movement is Limited to 

the Spine. 



each one. For this purpose the patient should wear during exercises 
a loose cotton dressing jacket, fastened around the neck and opening 
in the back. This protects the front of the body but permits inspec- 
tion of the spine. 

Such exercises should be simple and corrective in the strict sense; 
that is to say, an exercise which is of use should be seen to straighten 



GENERAL POSTURE AND PRECAUTIONS 139 

the spine visibly. Complicated exercises are dangerous and unsur- 
gical. Work to yield results must be given by a competent gymnast 
for a period of from one to three hours a day, according to the vigor 
of the patient, and must be continued under personal supervision for 
a period of some weeks or months to obtain satisfactory results. 
Af ter this, exercises at home can be substituted for part of the per- 
sonal work. 

As a preliminary to gymnastic work the heart of the patient 
should have been, of course, examined. Afterward the weight should 
be taken each week as persistent loss of weight is an indication for 




Fig. 94. — Apparatus for Fixing the Pelvis During Gymnastic Exercises. 

moderating or discontinuing temporarily the exercises, providing 
that the patient is not being overworked at school, in which case the 
school conditions should first be remedied. During menstruation, 
gymnastic exercises should be suspended. Persistent fatigue, anemia, 
loss of appetite, nervousness, and frequent or profuse menstruation 
should cause a careful investigation of the patient's environment, as 
they may arise from that or from excess of gymnastic work. 

The following list of gymnastic exercises, selected from a large 
number, may be regarded as representative of the kind of gymnastics 
likely to be of use within the limits mentioned above. They will first 



140 TREATMENT 

be described individually and then analyzed, and their application to 
different conditions will be indicated. The selection of exercises 
must depend on the requirements of each case. Simple develop- 
mental exercises have not been included here, as a description of 
them can be found in books on gymnastics. 

In the explanations to be given in connection with each exercise 
the general mechanical features will be discussed, but it must be 
remembered that conditions observed in the normal do not neces- 
sarily hold true in the deformed spine of scoliosis, although they form 
the best basis for analysis. The more nearly a spine approaches the 
normal, the more likely is such analysis to be correct. 

SYMMETRICAL EXERCISES 

Exercises in the Standing Position 

In all exercises given in this position the pelvis should be fixed unless otherwise 
stated. It must be remembered that exercises in this position call into play in 
varying relations all muscles concerned in maintaining the upright position, and 
therefore cannot be as highly specialized as can exercises given in the lying posi- 
tion. It must also be remembered that the superincumbent weight rests on the 
laterally curved spine, and that the curves are therefore not in as favorable a 
condition in such exercises as in the lying position. On the other hand, they are 
useful because any improvement of scoliosis must be interpreted as meaning 
improvement in the upright position, and all muscles concerned in that are 
therefore of importance. 

Fundamental Standing Position. — The patient stands with the knees extended, 
the hands on the hips, the back straight, the head erect, and the scapulae brought 
close to each other. The patient should not exaggerate the lumbar curve, and 
should press down w r ith both hands on the hips. 

I. Trunk Stretching. — (i) From the fundamental standing position the 
patient stretches the whole spine upward. The surgeon holds his hand slightly 
above the patient's head and urges her to stretch until she can touch his hand 
with her head, keeping both heels on the ground. The position of the hand is 
made higher as necessary. (2) From the upward stretched position the patient 
relaxes to the fundamental standing position. In count (1) the patient breathes 
in and in count (2) breathes out (Fig. 95). 

This is a general exercise calling upon the muscles which maintain the proper 
erect position, notably the spinal extensors. The elevation of the shoulders 
elevates and fixes the shoulder-girdle, giving a fixed point for the pull of the in- 
spiratory muscles, thus tending to increase chest capacity, and a general stretch- 
ing of the spine is also made easier by the fixed shoulder-girdle. The exercise 
is applicable to any case of scoliosis, especially to postural curves, as a general 
mobilizing and corrective one. 

II. Trunk Bending Forward with Trunk Stretched. — (1) The shoulders are 
raised as in Exercise I (1). (2) The patient bends her trunk forward to the hori- 
zontal position, the spine being held straight and the shoulders raised, movement 
occurring only in the hip-joints. (3) The patient raises the trunk to the upright 



SYMMETRICAL EXERCISES 



141 



position with the shoulders still raised and the spine straight. (4) The patient 
relaxes to the fundamental standing position(Fig. 96). 

This combines the essentials of Exercise I with the weight of the trunk thrown 
on the extensor muscles of the back and on the glutei, which must be held con- 
tracted to maintain the forward bent position and which must contract to bring 
the trunk again into the upright position. It has the corrective effect of Exer- 
cise I, in addition to which it is a fairly strong extensor spinal exercise with the 
lumbar curve flattened. It is a general mobilizing and corrective exercise 
which may be safely used in cases with a tendency to exaggeration of the lumbar 
curve. The patient inspires in (1), holds the breath during (2) and (3), and 
breathes out in count (4). 

The above exercises may be modified and made slightly harder by having the 
patient place both hands behind the neck with the elbows square back as far 
as possible. This raises the center of gravity of the trunk and therefore in- 
creases the leverage against the muscles. 




Fig. 95. 





Fig. 97. 



III. Trunk Twisting. — Position: Without pelvic fixation, the feet parallel and 
touching, the hands on the neck, the head and spine erect. (1) From this 
position the patient twists her whole body as far as possible to the right or left, 
the head being turned as far as possible in the same direction. (2) The original 
standing position is resumed (Fig. 97). 

Trunk rotation to the right causes a left dorsal curve and vice versa; in addition 
to this the exercise is intended to be mobilizing to the whole body, especially 
the hip-joints, and greater trunk excursion is possible with the feet parallel than 
with the legs rotated outward. The exercise is suitable for general spinal mobili- 
zation, and when given only to one side is a mild corrective exercise for lateral 
deviation. The effect of rotation upon the spine, especially in causing a lateral 
curve, may be located higher in the spine by giving the rotation in the forward 
bent position, and located lower by giving it in the hyperextended position. 



Exercises Given in the Horizontal Position 

In this group of exercises one set of muscles may be more readily picked out 
for exercise than in the erect position. The spine when prone is less curved than 



142 



TREATMENT 



in the upright position, and is slacker and more easily capable of side displace- 
ment. The fact that symmetrical hyperextensions are so much used for their 
corrective effect is explained by their empirical value and by anatomical reasons 
(page 32). 



J 








Fig. 98. 

Lying on the Face. — IV. Trunk Raising. — Position: The patient lies face 
downward on a table with the spine straight, the hands on the hips, the scapulae 
approximated to each other, and the legs secured to the table by a strap passing 
around the table and legs just above the ankles, or the legs may be held by the 
hands of an assistant. (1) The patient inspires and raises the trunk from the 
table, hyperextending the spine as far as possible, keeping the head^back and the 
face up, with the elbows still held well back. (2) The patient breathes out and 
sinks to the original position (Fig. 98). 

A 




Fig. 99. 



This is an extension of the spine from its normal position to extreme hyper- 
extension in which the spinal motion occurs largely below the tenth dorsal 
vertebra, where hyperextension anatomically takes place. The weight of the 
trunk is raised by action of the back extensor muscles which are very generally 
called into play. It is a general strengthening exercise for these muscles, but 
in cases with marked increase of the lumbar curve it must not be used to increase 
this, in such cases Exercise II being available. The latter is probably a weaker 
exercise, because in it the extensor muscles do not contract to their fullest ex- 



SYMMETRICAL EXERCISES 



J 43 




Fig. ioo. 




Fig. ioi. 




Fig. 102. 



144 



TREATMENT 



tent. The exercise may be made harder by placing the hands behind the neck 
and squaring the elbows back or by extending the arms beside the head, which 
raises the center of gravity (Fig. 99). 

The above may be modified in the following manner: The patient clasps his 
hands behind his back above the level of the waist-line, with elbows flexed and 




Fig. 103. Fig.. 104. 

hand closed against the back, and, as he hyperextends his trunk, stretches his 
arms backward forcibly, extending the elbows, and keeping the hands clasped. 
By this modification the scapulae and shoulder- joints are carried back and the 
hyper extension done with an improved position of the shoulders. This is par- 
ticularly suited to round shoulders. 




Fig. 105. 

This exercise may be made stronger by the use of dumb-bells or a staff as indi- 
cated in Figs. 100, 101, 102. 

Exercises Lying on the Face, the Trunk Projecting over the End of the Table.— 
The legs rest on the table, the surgeon making the ankles secure by means of 
a strap or by holding them. The body above the hip-joints hangs over the table 
end, head downward. The hands are placed behind the neck with the elbows 
squared back. 



>\MMETRICAL EXERCISES 



145 



V, Trunk Raising from Head Downward Position. — (1) The patient inspires, 
and raises the trunk as far as possible by hyperextending the hip-joints and the 
spine. (2) During the expiration she sinks to the primary position. The spine 
should be kept in the mid-plane and the head not allowed to flex (Fig. 103). 
i 

This is a spinal extension movement mostly without superincumbent weight, 
beginning at forward flexion and ending in marked hyperextension, calling the 
extensor muscles into activity from a stretched to a completely contracted condi- 
tion. It thus combines the range of motion in Exercise II with that of Exercise 
IV. It is a heavier exercise than either. From the start of the exercise till 
the horizontal position is reached the spinal extensors and glutei are the muscles 
chiefly active, as the maintenance of balance does not require the contraction 
of other trunk muscles. The exercise may be made easier by placing the hands 
on the hips. It is of use as a general strengthening exercise for the back muscles 
in any .case where the patient is strong enough to take it. 

Exercises Lying on the Back. — The patient lies on a table or on the floor with 
the head, trunk, and legs straight, and the feet secured either by a strap or by 
being held. The arms are folded on the chest. 



i ) 



\ \ * 




Fig. 106. 



^J 



VI. Trunk Raising to Sitting Position. — (1) The patient rises slowly to the 
sitting'position with the spine stiff and not allowed to flex. (2) The patient sinks 
to the' primary position with the spine still stiff, the head touching the table 
before the back (Fig. 106). 

The exercise is made easier by placing the hands on the hips, and harder by 
placing the hands behind the neck with the elbows squared back. The upright 
position is brought about by the contraction of the abdominal muscles, which aid 
in maintaining the upright position, and require exercise in cases of prominent 
abdomen and of increase of the lumbar physiological curve accompanying 
scoliosis and round shoulders. 



Miscellaneous Symmetrical Exercises 

VII. Weight Carrying on the Head. — A bag filled loosely with sand, weighing 
from 3 to 15 pounds, is placed on the top of the patient's head, and she walks 
slowly to and fro with the arms preferably clasped behind the neck and the elbows 
squared back. The exercise may be made more difficult by having the patient 
walk on tiptoe. The attitude assumed should be as erect as possible and the 
weight as heavy as can be carried steadily. 



146 



TREATMENT 



It is a matter of common information that the habitual carrying of baskets 
and loads upon the head induces an erect carriage and a straight spine. The 
presence of weight upon the head necessitates holding the spine as straight as 
possible under the weight, as it is thus most economically carried, and this in- 
stinctive adjustment to superincumbent weight is depended on for its corrective 
effect. The exercise is suited to mild cases with noticeable bad carriage and poor 
balance. 

VIII. Mirror Self -corrective Exercise. — The patient, bared to the hips, faces 
a mirror in front of which hangs a plumb-line. The patient then stands in such 
a position that the plumb-line cuts the middle of the pelvis, and by a muscular 
effort brings the middle of the thorax and the vertical line of the face as nearly as 
possible under the plumb-line, bringing three important landmarks into the 
median line of the body, thus securing an improved position. This is held for a few 
seconds and then the relaxed position resumed. The exercise is repeated several 
times, the improved position being held longer each time. 

The exercise is a muscle training and is not in any way a mobilizing exercise, 
but enables the patient to associate a certain position with a certain muscular 
effort, and is of great value in enabling patients to identify by muscular sense 
the corrected position. The exercise requires but little effort and may be done 
at home without assistance. It may be modified in various ways by adding 
free-arm, staff, or dumb-bell exercises, which change the center of gravity, 
strengthen muscles approximating the scapulae, and prolong the corrected 
attitude. 

ASYMMETRICAL EXERCISES 

IX. Hip Sinking (Hoffa). — Position: From the fundamental standing position 
the patient advances the foot, on the side opposite to the convexity of the lateral 
curve, forward and outward about two foot-lengths. (1) The patient bends the 
forward knee, sinking the hip on that side. (2) The patient resumes the primary- 
position (Fig. 107). 






Fig. 107. 



Fig. 108. 



Fig. 109. 



A passive side correction of the lumbar curve, due to a lowering of the pelvis 
on the side of the advanced leg when the knee is bent. Suitable for lumbar 
curves. 

X. Self -correction (Lorenz). — The patient assumes the fundamental standing 
position and places the hand of the side to which the dorsal spine is convex upon 



SYMMK IR1CAL EXERCISES 



147 



the side of the thorax opposite to the greatest dorsal curve; the other hand is 
then placed on the ilium. (1) By a side thrust of the hand on the thorax the 
patient corrects the dorsal curve as much as possible, maintaining the correction 
tor a few seconds. (2) The patient relaxes to the primary position. The exercise 
may be modified by placing the hand on the side to which the dorsal spine is con- 
cave on the top of the head, as it thus tends to raise a low shoulder. The rest of 
the exercise is performed as described (Fig. 108). 

A side thrust of the dorsal spine with pressure applied to the convexity of the 
dorsal curve against resistance furnished by the other hand on the ilium or the 
head. Suitable for dorsal scoliosis, but not powerful, and useful as a means of 
stretching; chiefly good because it can be done by the patient unaided at frequent 
intervals. Exercises IX and X may be combined for a double curve with one 
element dorsal and the other lumbar. 

XI. Hip Sinking from Stool. — Position: The patient stands erect on a stool 
on one foot (the foot on the side of the convexity of the curve). (1) The patient 
lets the free leg sink as much as possible, thus lowering the pelvis and hip on that 
side. The knee of the supporting leg must be kept straight. (2) The patient 
resumes the original position (Fig. 109). 

A passive side stretching of the lumbar curve suitable for lumbar scoliosis* 
The leg and pelvis drag down on the side of the concavity of the lateral cuver, 
tending to stretch contracted structures and straighten the curve. 




XII. Trunk Hyper extension with Side Bending — Lying on the Face. — The 
patient lies face downward on a table or on the floor as described in Exercise 
VII. (1) The trunk is raised from the table as far as possible by hyperextending 
the spine. (2) From this position the trunk is bent to the side toward which the 
lumbar curve is convex. (3) Position 1 is resumed. (4) The prone lying position 
is resumed (Fig. no). 

This exercise is an active lateral flexion of the spine in the position of hyper- 
extension. As hyperextension locks the dorsal region against side flexion, the 
movement is almost wholly confined to the lumbar region. If there is a right 
dorsal curve in connection with a left lumbar curve, bending to the left, while 
it corrects the lumbar curve, does not at the same time greatly increase the dorsal 
curve, as that part of the spine is locked against side bending. The exercise is, 
therefore, suited not only to lumbar curves, but especially to compound curves 
in both dorsal and lumbar regions. 

XIII. Drawing tip the Hip — Lying on the Face. — Position: The patient lies 
prone on a table, holding the end with both hands, the arms extended and the 
spine and legs in a straight line. (1) The surgeon grasps the ankle on the side of 
the lumbar convexity and resists while the patient draws the hip up as far as she 
is able, knee the being kept straight. (2) Position 1 is resumed (Fig. in). 



148 



TREATMENT 



The approximation of the side of the pelvis and the thorax on the side to which 
the lumbar curve is convex is brought about by an active contraction of the 
muscles on the convex side of the lumbar curve which it is desirable to develop. 
The amount of work thrown on these is determined by the amount of traction 
made on the ankle. The exercise is suited to cases of lumbar curves or to the 
lumbar element of compound dorsal and lumbar curves.. 




Fig. 112. 

XIV. — Side Flexion of the Trunk from the Side-lying Position. — Position: The 
patient lies on a table with the concavity of the lateral curve downward and the 
trunk projecting over the edge of the table above the pelvis, the patient being 
supported in this position, and the ankles secured by means of a strap. The spine 
is held in medium extension, the upper hand on the hip and the lower hand on the 
back of the neck, (i) The trunk is bent laterally and upward as far as possible. 
(2) The original supported position is resumed (Fig. 112). 





Fig. 113. Fig. 114. 

In this exercise the weight of the trunk is thrown on the muscles of the convex 
side of the lateral curve. The raising of the trunk tends both to diminish a 
curve existing near the dorsolumbar junction and to exercise strongly the muscles 
which aid in its correction. It is suited to total, lower dorsal and dorsolumbar 
curves. 



\S\M METRICAL EXERCISES 



149 



X\". Trunk Holding to Both Sides with Hand Pressure (Mikulicz). — Position: 
In the case oi a light dorsal left lumbar curve the patient places the right hand 
on the prominence of the ribs just under the shoulder-blade, and the left above 
the ilium on the lumbar curvature. (1) She then bends the body slowly to the 
right side, while the right hand and thumb press against the dorsal prominence. 
: ' The upright position is resumed. (3) The patient bends to the left and 
backward, pressing with the left hand against the lumbar curve. (4) The up- 
right position is resumed (Fig. 113). 

This is a combined mild active and passive correction for a double curve. 
Opposing forces are applied to the convexities of the curves, thus tending to 
straighten the spine, which is at the same time bent by means of muscular action, 
first to the side of the convexity of the dorsal curve and then to the side of the 
convexity of the lumbar curve. 

XVI. Passive Head Side Bending. — Position: The patient stands with the 
hand on the side of the concavity of the lateral curve against the side of the head 
above the ear. (1) The head is pushed as far as possible to the side that corrects 
the curve. (2) The original position is resumed (Fig. 114). 

A passive correction of the cervical lateral curve by a side bend of the upper 
part of the cervical region which tends to diminish the curve. Of use in cervical 
and cervicodorsal curves, either alone or existing in combination with others. 





Fig. 115. 



Fig. 116. 



XVII. Trunk Raising with Asymmetrical Position of Staff— from Prone Lying 
Position. — Position: The one described for exercises with the patient lying on the 
face (Exercise VII) with a staff grasped in both hands, the arms being extended 
beside the head. (1) The trunk is raised from the table and the staff brought 
over behind the head obliquely, the hand on the side of the convexity of the curve 
being carried down toward the feet, and the other carried up over the head until 
the staff is brought as nearly as possible into the long axis of the body and pressed 
against the back. (2) By a reversal of the movement the original position is 
resumed (Fig. 115). 

The scapula on one side is raised, and the position of the staff tends to correct 
an existing curve in the dorsal region. The exercise amounts to a spinal hyper- 
extension in a corrected position of the dorsal spine. The exercise is suited to 
total curves, to simple dorsal curves, and to compound dorsal and lumbar 
curves. 



i^o 



TREATMENT 



XVIII. Partial Suspension by One Arm with Other Arm and Leg Locked. — 
Position: The patient standing by a ladder or under a bar that can be reached 
without rising on the toes, grasps one rung of the ladder or the bar with the hand 
of the side to which the spine is concave. On the opposite side, the convex, the 
arm passes under the knee, the thigh being flexed at the hip, and the shoulder 
and pelvis are thus approximated, (i) The patient thus standing on one leg 
flexes that knee and allows the body-weight to come upon the arm. (2) The 
original position is resumed (Fig. 116). 

When the arm is placed under the knee the pelvis and shoulder are approxi- 
mated on that side and the spine made convex to the other side as far as it will go. 
The structures on the concave side are thus put on the stretch and, by allowing 
the body-weight to come on the arm holding to the ladder, a further stretching 
force is exerted on the structures on the concave side. The exercise is suited 
to total and dorsal curves. 

Creeping Exercises (Klapp). — In these exercises the patient supports the 
trunk in a horizontal position with the hands and knees or feet on the floor. The 
hands, knees, and toes should be protected by leather pads which are strapped on. 




Fig. 117. 



Fig. 118. 



XIX. Symmetrical Creeping. — The hand and knee of the right side are placed 
close together with the hand to the outer side of the knee, the head is twisted with 
the face to the right, and the trunk is rotated with the left shoulder upward. 
The left arm is extended beyond the head and the hand placed on the floor, palm 
down and fingers forward, as far forward as possible and directly in front of the 
right knee. The left knee is placed as far back and as near the median line as 
possible; the spine is strongly bent to the right. The creeping consists of forward 
locomotion by a series of reversals and regainings of the position described. The 
mechanism of the first reversal is as follows : the left knee is drawn forward to the 
inner side of the left hand in its original place and position, the right arm is 
extended above the head, and the hand placed as far in front of the left knee as 
possible with the palm down and fingers front. At the same time the spine is 
rotated to bring the right shoulder high, the face is twisted to the left, and the 
spine flexed to the left. The restoration to the first position is secured by again 
moving the back knee (right) and the back hand (left) (Fig. 117). 

This is a general muscle strengthening and spine-mobilizing exercise. It is 
comparatively mild and may be continued for long periods of from twenty to 
forty minutes. Symmetrical creeping is properly that which is done rapidly, 
and is of most value in restoration of flexibility. 

A modification is made by creeping slowly, holding each position and putting 
force into the stretching, usually holding the position longest which stretches the 
concavity of the most marked curve (Fig. 118). Another modification is creep- 
ing in place, which differs from the above in that the patient does not attempt 
locomotion. The position is somewhat as above except that the fingers of 
both hands are placed on the floor opposite to the side to which the face looks. 
The trunk is rotated till the side with the forward arm is uppermost, and the arm 
is carried directly over the head, while the under arm is flexed at the elbow which 



.1 AC 'RETS AND BRACES 



151 



points to the side toward which the face is turned; the posterior knee is straight- 
ened, and the foot only of that limb touches the floor. The patient then endeav- 
ors to look upward beneath the forward reaching arm. This is best employed 
as an asymmetrical exercise to correct the dorsal convexity and stretch the 
side of the concavity (Fig. 119). 

XX. Creeping Sidewise. — There is a third asymmetrical variation in "creeping 
sidewise" toward the side showdng the concavity of the curve to be corrected, for 
example, in a left total curve. The patient creeps sidewise to the right. The left 
hand and knee are placed under the trunk, and as far as possible to the right of the 
right hand and knee. The right hand and knee are then advanced to the right 
and the above is repeated. The face should look to the left (Fig. 120). 

This is a corrective exercise similar to other forms of creeping, and may also 
be used for dorsal curves as well as for those of the total type. 




Fig. 119. 



Fig. 120. 



XXI. Creeping with Arm Flinging Upward. — Another kind of creeping in which 
the upper part of the spine is especially concerned is the creeping with arm 
flinging upward. The starting position is the same as for ordinary creeping — 
hands and knees on floor, hand and knee of one side touching, hand and knee of 
opposite side stretched far apart. The patient brings up the backward knee until 
it touches the forward hand, then raises the opposite hand from the floor, and with 
elbow r straight swings the whole arm upward so that the impetus of the swing 
twists the dorsal spine and causes the whole trunk to turn. At the same time the 
patient turns her head and looks up at the hand that is raised. This stretched 
position is held for a second, then the arm is swung downward again and the hand 
placed as far forward on the floor as possible. 

(2) JACKETS, BRACES AND CORSETS 

Braces and corsets of themselves have no place in the corrective 
treatment of lateral curvature, and are only to be regarded as a 
means of retaining the gain secured by other methods. They must 
be regarded as having in themselves little corrective value, for such 
apparatus applied to the spine not previously loosened up by treat- 
ment is not able to secure any considerable correction by pressure 
on the spine because the base for the leverage to be obtained from 
the pelvis must consist in a pressure obtained from the space be- 
tween the crest of the ilium and the top of the trochanter. Direct 
pressure on the crest of the ilium is not tolerated, and pressure on 
the trochanter interferes with walking and sitting. It is manifestly 



152 



TREATMENT 



impracticable from this small space to obtain a hold which will 
exercise a sufficient side thrust on the thorax to be corrective. The 
current practice of the instrument-makers of fitting corsets and 




Fig. 121. — On the Left is a Plaster Torso Made from a Corrective Jacket. On 
the Right is the Same Torso Made More Symmetrical for the Application of a Re- 
movable Jacket. 

braces to such patients and allowing the parents to hope for any 
considerable benefit is therefore to be condemned. 

The complicated braces in former use have been largely displaced by 




Fig. 122. — Brace for Scoliosis, Back. 
— (£. H. Bradford.) 



Fig. 123. — Brace for Scoliosis, 
Front. — (E. H. Bradford.) ■ 



the jacket or corset. They maybe found described in the references. 1 

The corset used in Germany is shown in the illustration (Fig. 126). 

1 Hoffa: "Lehrb. d. orth. Chir.," fourth ed., 1905, page 429; Redard: "Chir- 
urgie Orthopedique, 5 ' Paris, 1892, page 382; Bradford andLovett: "Orth. Surg.," 
first ed., 1890, page 168. 



JACKETS, BRACES AND CORSETS 



153 




Fig. 124.— Brace for Scoliosis, Fig. 125.— Brace for Scoliosis 

Back.— (Z. B. Adams.) Front.— (Z. B. Adams.) 





Fig. 126.— Corset for Scoliosis Strength- Fig. 127.— Brace for a Case of Right Dorsal 
ened by Steel.— (Dolega.) Scoliosis, Applied.— (C. W. Keene. 



154 TREATMENT 

The braces of Bradford, Adams, and Keene are representative of 
the best types of modern retention braces, but in the writer's ex- 
perience better correction is maintained by removable jackets than 
by braces. 

Under the conditions specified the choice between a removable 
jacket, a corset, or a brace, will be determined by the facility of 
the surgeon with each. 

(3) PASSIVE STRETCHING OF THE SPINE 

It is at times desirable to increase flexibility of the spine more 
rapidly than can be done by free standing gymnastics alone and 
stretching of the contracted structures is in all cases of structural 
scoliosis except the mildest more easily to be obtained by intermit- 
tent passive stretching in apparatus than by gymnastics alone. 
The following considerations bear on the use of stretching force as 
applied to the spine whether in intermittent stretching or in forcible 
correction. 

The least economical use of force in straightening, for example, a 
bent stick is to pull the two ends away from each other, i.e., to 
straighten it by a pull in its length. The most economical use of 
force is to take it by the two ends and press the point of greatest 
convexity against some resisting point which shall push it straight. 

Again, if one wishes to secure the greatest side displacement in a 
flexible rod, such displacement is more easily secured when the rod is 
not stretched in its length. If a rubber tube, for example, is fastened 
to a table by two pins, one at each end and is not put on the stretch, 
the middle of it can easily be pulled an inch to one side by the fore- 
finger. If, however, it is pinned to the table by two pins separated 
enough to hold it on the stretch, it will require much more force to 
displace it one inch to the side. The same is true of a strip of sponge 
rubber or a piece of rattan. 

To be sure that this theoretical consideration applied to the human spine the 
following experiment was made at the Harvard Medical School by the courtesy 
of the late Prof. Thomas D wight. . 

Head suspension is a passive stretching of the spine, corrective through its 

entire length, tending to improve both rotation and side deviation at the curves, 

but exercising still more force upon the more nearly normal parts of the spine 

because the latter are more movable. Suspension by the arms is less efficient, 

' and does not affect the cervical vertebrae as does head suspension. 

A young male cadaver was laid on the face, and straps passed around the body 
at the level of the right shoulder and the right hip. These straps were then 
fastened to the left side of the table, holding the shoulder and hip against pres- 



STRETCHING OF THE SPINE 



155 



sure from the left. A strap was then passed around the left side of the thorax 
and by means of a spring balance pulled to the right. The side deviation of the 
spine was then measured at four levels, the measurements being taken from a 
base-line connecting the cervical spine and the sacrum. The measurements were 
all made from pins driven into the spinous processes. Three experiments were 
made with a side pull of 25 pounds and the results were recorded. 

A Sayre head-sling was then put 
around the head of the cadaver still 
lying on the face, and a traction force 
of 75 pounds was made in the length 
of the spine, the feet of the cadaver 
being fastened to the table. While 
the traction on the head was thus in 
force the same side pull of 25 pounds 
was made as before and the results 
noted. Two experiments of this sort 
were made. It was found that the 
spine without traction was displaced 
to the side nearly twice as far by 
a definite side pull as by the same 
amount of side pull when traction 
was being made. 

A confirmatory experiment was 
made on a healthy boy of fifteen, 
using 75 pounds of head traction and 
15 pounds of side pull. The result 
was the same. 

The conclusion is that extension of 
the spine by an upward pull on the 
head is a corrective force in the nor- 
mal spine, but that much more force 
is required to accomplish a certain 
amount of side correction than is the 
case if the force is applied from the 
side. 

The other conclusion is that to 
secure the maximum of side dis- 
placement from a given amount of 
side pressure the spine must be slack 
and not stretched in its length. p IG . 12 8.— Head Traction. 




(4) PASSIVE STRETCHING BY SUSPENSION 

The patient stands or sits erect, and the head is pulled vertically upward by 
means of a Sayre head-sling, which embraces the chin and occiput. Traction 
should be made by a compound pulley, and the patient or the surgeon may hold 
the rope. Suspension is mildest — (1) when the feet are not made to leave the 
floor; next in grade comes (2) the position of tiptoe induced by the traction, and 
(3) a greater pull is secured by lifting the whole body until the feet swing free. 



i56 



TREATMENT 



In this case the traction force equals the body-weight. The maximum traction 
can be secured (4) by strapping the thighs down to a seat on which the patient 
sits. An upward pull greater than the body-weight can now be exerted on the 
head (Fig. 128). 

Apparatus for the purpose has been devised, and is known as the 
Weigel-Hoffa frame, in which the patient is suspended by the head, 




Fig. 129. — Stretching Board with Loops, Ready for Application. — ("Jour. Am. 

Med. Assn. 1 ') 




Fig. 130. — Stretching Board with Loops Applied Tq a Patient. Reverse of Fig. 129, 
— ("Jour. Am. Med. Assn.") 



while pads are run in from the sides of the frame, making lateral pres- 
sure on the trunk in various directions. 

Correction of the lateral curve of the spine is, however, to be 
obtained more economically by having the patient lie prone, and the 



FORCIBLE CORRECTION 1 57 

corrective force should be divided into two elements, the force to 
correct the rotation and the force to correct the side deviation. A 
simple apparatus for this is as follows (Fig. 129) : 

The patient lies face downward, with the knees flexed, on a board three feet 
wide by four feet long. Assuming the case to be of a right dorsal curve, a broad 
canvas strap is passed around the left thorax, over and under the patient, and 
fastened to a cleat on the right side of the board. This furnishes a point of 
pressure to the left against the upper thorax at the level of the axilla. A broad 
canvas strap is then passed around the pelvis of the patient above and below, and 
is fastened to a cleat at the right side of the board. This furnishes a point of 
pressure to the left at the level of the pelvis. A broad canvas strap is then passed 
around the thorax at the level of the greatest point of curve; it passes above and 
below the thorax and its upper end is fastened to a cleat at the left side of the 
board (Fig. 130). Its lower end is fastened by means of a string into a compound 
pulley attached to a cleat at the left side of the board. By means of this pulley 
any reasonable degree of force may be exerted against the right side of the thorax, 
pulling it to the left, and at the same time that it pulls, it tends to reduce the 
rotation from the fact that its upper end is fastened and its lower end moving 
toward the pulley. 

(5) FORCIBLE CORRECTIOX 

In marked moderate and in severe structural lateral curvature no 
means of treatment is in the opinion of the author so efficient as con- 
tinuous stretching by means of plaster jackets applied under force. 
This method is spoken of as "forcible correction." Such jackets are 
applied with the purpose of stretching the contracted structures and 
of inducing an improvement in the curve. 

From the time of the elder Sayre, who advocated for scoliosis the 
application of plaster jackets applied in mild suspension, in several 
papers between 1875 and 1885, there had been sporadic attempts at 
the use of continuous mild corrective force in the treatment of scolio- 
sis. Dating from the work in 1896 of Calot 1 who advocated at that 
time the use of forcible correction in' the treatment of Pott's disease, 
the attempts became more forcible. Schanz 2 published in 1900 an 
account of an efficient technic in suspension, and reported results 
in 1902. In 1 901 the author reported results and described a technic 
where the patient lay on the face during the application, 3 and there 
were other papers written at about this time, but the great impetus to 
the treatment by forcible correction came from Wullstein, 4 who read 

1 Calot: "France Med.," 1896, 52; 12th Int. Med. Congress, Moscow, 1897. 

2 Schanz: ''Munch, med. Woch.," 1900, Bd. xlvi. 

3 Lovett: "Trans. Amer. Orth. Asso.," 1901, vol. xiv; "Boston Med. and 
Surg. Jour.," October 31, 1901. 

4 "Zeitsch. f. orth. Chir.," 1902, Bd. x. 



158 TREATMENT 

a paper at the International Medical Congress in Paris in 1900, and 
who published his experiments, method, and results in 1902. He 
showed experimentally that bony scoliosis could be produced in 
young dogs and by the use of plaster-of-Paris jackets applied to sco- 
liotic patients in an improved position, induced by the use of traction 
and lateral pressure, both of high degree, he secured results that were 
better than any previously reported. The work attracted much 
attention, and markedly modified the whole point of view with 
regard to "forcible correction," which began to gather a body of 
adherents whose number has steadily increased. 

The object of the corrective jacket being to force the spine into 
the best obtainable position, and in that position to apply a retentive 
plaster jacket, it becomes pertinent to inquire in what position and 
by what technic the best corrected position may be obtained. 

Five positions are to be considered; these are with the patient 
suspended and lying on the face, side or back, and in the rotated 
position advocated by Forbes. 1 

Application in Suspension. — Sayre's jackets were applied with the 
patient suspended by the head with the heels lifted from the ground, 
and ke claimed for them nothing more than support in an improved 
position. The jackets were removable, and exercises were done 
daily. The treatment was too mild to be effective, and although 
extensively used was not followed by very successful results. 

Wullstein's method was also a suspension method, but he used 250 
pounds of traction, and to secure this, the patient was strapped by 
the thighs to a revolving and tilting stool and lateral pressure was 
secured by pads running in from an upright frame on horizontal rods. 
These pads were incorporated in the jacket. Much greater force was 
used than ever before, and although unpleasant symptoms from pres- 
sure arose at times, the results were so good that the method was 
extensively used, and is still in vogue on the continent of Europe. 

The method of Schanz is simpler and in connection with the after- 
treatment highly efficient if one may judge by the admirable results 
obtained, but at the same time an amount of traction is used which 
is objectionable if the same results can be obtained by other means. 
The patient stands and the ankles are fastened by anklets to rings 
bolted to the floor. By means of a Sayre head sling extension is pro- 
duced by means of a windlass to the point of the patient's tolerance. 
A plaster jacket including the shoulders is then applied and as it is 
hardening the surgeon passes his arms around the pelvis of the patient 

»"N. Y. Med. Journ.," July 6, 1912. 



FORCIBLE CORRECTION 



159 



and with his shoulder protected by a pad, presses against the rotated 
and curved portion of the spine. The after-treatment followed by 
Schanz consists in prolonging recumbency in a corrected posterior 
plaster-of-Paris shell with head traction. The patient is turned once 
a day onto the face to have the back massaged, but no exercises are 




Fig. 



131. — Patient with Plaster Jacket Applied in Wullstein's Apparatus. 

— (Wullstein.) 



given at this period. After months of recumbency a corset and 
headpiece are applied and the patient allowed gradually to sit up. 
At a later period exercises are begun. 

Advantages and Disadvantages of Suspension Positions. — The use 
of strong traction in the length of the spine tends to straighten the 
lateral curves and to diminish the rotation, but without added lateral 



i6o 



TREATMENT 



pressure sufficient correction is not obtained. Moreover, traction 
in the length of the spine makes it resistant to side displacement 
from lateral pressure, as a stretched spine is less easily displaced to. 
the side than a slack spine. Wullstein found that he must diminish 
the traction on the head to get the best results from side pressure. 
But the upright position is the one in which the patient will wear 
the jacket; the technic of application is in this position the simplest, 
access to the shoulders and neck is easy, and the lower part of the 




Fig. 132. — Appliance for Lateral Suspension and the Application of Retentive 
Casts. — {Rich, "Jour. Amer. Med. Assoc," Dec, 1911.) 



jacket can be accurately fitted to the pelvis. Under these conditions 
a close-fitting and presentable jacket can be most easily applied by 
this method. 

Application of Corrective Jackets Lying on the Side. — A method 
has been devised by Rich 1 in which the patient lies on the side and 
is suspended by a sling passing around the convexity of the lateral 
curve, other slings hold the head and pelvis, and rotation is con- 
trolled by an oblique pull. The jacket is applied as a figure eight 

1 "Jour. Am. Med. Assn.," Dec. 30, 191 1. 



FoRnr.i.i: cokrectiox 



161 



bandage, with the upper turn embracing the root of the neck, the 
lower turn the pelvis, and the crossing coming over the convexity of 
the spinal curve. 

Advantages and Disadvantages of the Side Lying Position. — The 
chief advantages of this posi- 
tion consist in the fact that 
the patient is suspended, 
and thus all parts are easily 
accessible. The figure-of- 
eight bandage fulfils admir- 
ably the mechanical require- 





Fig. 133. — Anterior View of Pa- 
tient Showing Freedom of Chest 
over Areas of Concavity. — (Rich, 
" Jour. Amer. Med. Assoc, Dec, 
ion.) 



Fig. 134. — Patient Thirteen Years Old. 
Curvature Due to Rickets; Never Treated. 



ments, and the body weight is utilized to straighten the spinal 
curves. The method is not applicable, except to children. 

Application of Corrective Jacket in the Prone Position. — When 
corrective jackets are applied to the patients prone, it is desirable to 
flex the legs, as this diminishes the physiological curves of the spine 
and simplifies the problem. With a patient thus lying prone, the 
spine is open to inspection and relaxed. In this improved position 
the jacket is applied. 



l62 



TREATMENT 



A simple application of this method is to be found by having the patient lie 
prone in a rectangular gas-pipe frame on two straps of webbing running from 
end to end, cross straps supporting the pelvis and shoulders. By means of web- 
bing straps attached to the side of the frame, in a right dorsal curve, one going 
around the left side of the pelvis and another around the left upper thorax, while a 
third pulls on the right side of the thorax against these as points of resistance, 
great force may be exerted on the spine, much more force than can be safely used. 
With the patient lying prone on the webbing strips which are padded, the pelvic 
and axillary straps are adjusted to the proper tension and tied around the side 
of the frame. A heavy pad of felt is then applied over the rotated and curved 





Fig. 135. — Patient Lying in Correc- 
tive Frame, Showing the Improvement 
Gained by the Horizontal Position. 
Photograph taken from above. 
Patient same as in Fig. 134. 



Fig. 136. — Patient in Corrective 
Frame with Side Pressure Applied 
by Strap. 

Showing additional correction to that 
in Fig. 135. 



portion and a webbing strap attached to the side of the frame and tied at one 
end. This strap is then passed over the rotation, under the patient and back 
to the frame. By pulling on this end of the strap (the upper end of which 
has already been tied) the curved portion of the spine is pulled to the side and 
the rotation acted on by the twisting action of the strap. When sufficient 
tension has been obtained the end of the strap is fastened to the frame. The 
jacket is then applied with the side webbing straps in place, the bandages being 
worked around the straps. When the plaster is sufficiently hard these side 
straps are cut off where they emerge from the jacket and a finishing bandage 
applied. The patient then stands up; the longitudinal straps are pulled out, 
the jacket is cut out under the arms and by plaster bandages the jacket should be 



P] \>IKR JACKETS 



163 



extended to include the shoulders, 
tolerated. 



which is always desirable, but not always 



/ 



Mechanics and Technic of Application of Jackets in Prone 
Position. — When it comes to the application of corrective force 
it must be remembered that there are two elements in the deformity, 
namely, side deviation and rotation. A single correcting force 
would therefore have to be oblique, e.g., in a right dorsal curve for- 
ward and to the left. But for practical purposes it is desirable to 
use two forces, one forward and one laterally toward the spine, 
thus dealing separately with the 
two elements of the deformity. 
To attempt to correct the side 
curve by lateral pressure without 
attacking the rotation is likely to 
result in increase of the rotation 
by pressure on the already flat- 
tened shafts of the ribs. 

That this is not new may be 
appreciated by a quotation from 
Schreger 1 in 1810: "Der seitliche 
Druck auf die Rippen biege diese 
an den ohnehin schon mehr spitzen 
Wikeln noch mehr spitzig zu." 
That plaster jackets may cause 
increase of the rib angles is 
demonstrated by Hiissey. 2 The 
same point, that plaster jackets 
may increase the bony rotation 
apparent in the back, has been 
alluded to by Schulthess and 
Vulpius. 3 

It may, therefore, be stated that attempts to diminish the lateral 
curve, by pure lateral pressure, not carefully antagonized, will result, 
in fixed curves, in an increase of the rotation. 

The solution lies in dealing separately with the rotation and with 
the lateral deviation. Having corrected the lateral deviation first, 
this correction is held, as will be described, while the rotation is 
corrected or vice versa. In this way one element is not improved at 
the expense of the other. 

1 Fischer, quoted by Hiissey. 

2 Hiissey: "Zeitsch. f. orth. Chir.," viii, 2, 235. 
Vulpius: ' : Yolkmann's Samml. klin. Vort.," 276. 



Fig. 137.— On the Left is a Diagram 
Showing a Right Dorsal Left Lumbar 
Curve. 

In the middle diagram the curve is 
shown straightened; on the right the 
curve has been pushed over to the left 
unchanged. 



164 TREATMENT 

Technic of Application. — The patient should preferably be stretched once or 
twice daily for two or three days preliminary to the correction, but this is not 
essential. Anesthesia is never necessary, as all endurable correction may be 
obtained without much pain. A seamless undervest is put on and the iliac 
crests padded with heavy felt; a pad should also be placed over the sacrum. 
Under the side straps heavy felt or cotton pads are required. 

The correction is pushed to the point of causing mild discomfort, and difhculty 
in breathing is a sign of too much correction. The amount to be obtained in any 
case is better decided by the patient's sensations than by any theoretical stand- 



Fig. 138. — Patient of Whom Radiograms were Taken before Treatment. (January, 
1906.) — ("Am. Jour. Med. Assn.") 

ard. The danger lies on the side of obtaining too much rather than too little 
correction, for the jacket will be much more uncomfortable when the erect posi- 
tion is assumed. 

After correction the patient should remain in a hospital under close obser- 
vation for at least twenty-four hours. Some shock is not infrequently experi- 
enced and in a case of the writer's very serious collapse and cyanosis followed 
the correction of a severe curve due to infantile paralysis in a child of six. Wull- 
stein has recorded the occurrence of somewhat serious symptoms following 
correction. 

Advantages and Disadvantages of the Prone Position. — The spine 
in this position is slack and easily displaced to the side and twisted, 



APPLICATION OF JACKETS 165 

and the back is in view of the surgeon during the application, enab- 
ling him to see just what correction is being accomplished. But 
jackets applied by this method are clumsy, as it is difficult to fit the 
pelvis accurately, especially if the thighs are flexed, access to the 
chest and shoulders is not easy, and the front of the jacket is con- 
cealed from the surgeon's view. 

Application of Jackets in the Rotated Position {Forbes Method). 1 
— The method assumes that it is probable that the deformity arises 
in some cases from the rotation of the vertebral bodies and that an 
artificial scoliosis in the other direction should be induced to counter- 
act it. But such an assumption does not seem to be borne out by 
what we know of the occurrence of scoliosis. Nor does untwisting 
one part of the rotation seem likely to be of much use when such a 
complicated set of rotations exist as one finds in compound structural 
scoliosis. The justification of such a method would have to be 
found in the fact that it produced correction. In this matter one 
may rely on the verdict of the Scoliosis Committee of the American 
Orthopedic Association who examined six cases to be treated by 
this method in October, 19 14, and again in April, 191 5, after six 
months of treatment. Their report is as follows: 2 "They were all in 
fairly good condition but in two cases collapse seemed imminent 
after the jacket had been removed and the patients kept standing for 
inspection. Not only had overcorrection not been secured in any 
case, but in none was there marked diminution in any elements of the 
deformity. . . . The treatment of all the cases in this group seemed 
to have been carried out with great care and perseverance, but 
the Committee feel justified in considering the results as distinctly 
discouraging/' 

In view of what has been said the treatment is not in the writer's 
opinion to be recommended until further evidence of its practical 
value is brought forward. 

Application of Jackets Lying on the Back with the Spine Flexed 
(Abbott's MeJiod). 3 — The patient lies on the back w r ith the legs flexed 
on the trunk, the back rests on a hammock about a yard long and 
fifteen inches wide cut obliquely across one end. This hammock is 

1 Forbes: "N. Y. Med. Journ.," July 6, 191 2; Maidermot: "American Journ. of 
Orth. Surg., Feb., 1913; Forbes: "Surgery, Gyn. and Obst.," April, 1914; Adams: 
"American Journ. of Orth. Surg.," July, 1914. 

- '•American Journ. of Orth. Surg.," July, 1915, page 6. 

3 Abbott: "Simple, Rapid and Complete Reduction of Deformity in Fixed Lateral 
Curvature of the Spine," "X. Y. Med. Journ.," June 24, 1911. 'Forcible Correc- 
tion of Lateral Curvature of the Spine, a Simple and Rapid Method of Obtaining 
Complete Correction," "N. Y. Med. Journ.," Apr. 27, 191 2. 



1 66 TREATMENT 

fastened at each end to a steel rod by which it is loosened or tightened. 
It is held in place by being slung between the ends of a gas-pipe frame 
about five and one-half feet long and two feet wide. This frame rests 
on four gas-pipe legs and has a bar running lengthwise in the middle, 
about two feet above the main level of the frame to which the legs are 
slung, and nearer the ground are side bars to which straps may be 
attached. The patient is padded with thick felt and laid on the back 
on the frame and the legs are flexed and fastened to the upper rod, 
the shorter side of the hammock resting against the bulging ribs, a 
crosspiece of webbing supports the neck. Cross straps are now ap- 
plied around the body to pull in the desired direction, one in the 
axilla of the low shoulder carried obliquely across the frame to the 
upper corner, another around the pelvis pulling across to the same 
side of the frame as the axillary strap, another strap is passed over the 
most convex part of the dorsal lateral curve to the opposite side of the 
frame to pull on the dorsal curve and a fourth strap, wider than the 
others, may be used to pass from the side of the frame running over 
the anterior protruding ribs and hanging down. To this weights 
may be attached to influence the rotation. A large oval felt pad is 
placed over the back of the thorax on the side where the ribs are 
depressed. The straps are tightened and the jacket applied. 

In trimming the jacket it is left long behind at the bottom to main- 
tain flexion of the spine; at the top it is left high under the arm which 
has been elevated, but is cut away on that side in front; beneath the 
other arm it is trimmed low but left high in front to hold that 
shoulder back. A large window is cut in the back over the concave 
side, reaching well around to the side so that the spine may swing 
not only back but to the side, on the opposite, side in front a window 
is cut to allow the depressed ribs on that side to bulge anteriorly. 
After the jacket has been worn for a short time pads of felt are in- 
serted in front to push the ribs back through the window cut behind 
and sometimes pads are also to be used over the convexity at the 
back. 

Choice of Method. — In choosing between these methods it is prob- 
able that most of them are efficient and that the especial technic 
employed is probably less important than the skill of the surgeon and 
his experience with the particular method employed, the amount of 
force used and the efficiency of the after-treatment. But one fact 
must be borne in mind, there are two kinds of correction, one a real 
correction of the spine of which the .T-ray is the only criterion, and 
second, an apparent correction in which the thorax is rotated on the 



DISCUSSION OF METHODS 1 67 

spine with great improvement and perhaps even overcorrection of the 
body outlines but in which an :v-ray shows the lateral curve to be largely 
or wholly unchanged. In other words it is easier to rotate the thorax 
on the spine than to change the curve of the spine itself and herein lies 
the weakness of the method advocated by Abbott in which the thorax 
is most easily to be rotated on the spine — apparent correction, that 
is, correction of body outline, has figured in many reported cases in 
which the .r-ray has not been shown and where progress has been 
judged only by photographs. An instance of this is given in the 
figures (Figs. 155 and 156). The prone lying and suspension 
methods do not render the thorax so easily movable on the spine 
and it is probable that force expended in correction is more nearly 
spent on the spine itself. But the whole question as to choice of 
methods is sub judice. 

As to the overcorrection of the curve in marked or severe struc- 
tural scoliosis, such a claim must be substantiated by very weighty 
evidence for such an overcorrection would be contrary to all that 
we know of bone pathology, and a claim of such overcorrection is not 
lightly to be accepted. 

A committee of the American Orthopedic Association appointed 
in 1913, in June, 191 5, reported as follows: They had sent out a 
questionnaire to fifty members of the association in which the 
following two questions were asked: 

"1. Have you personally had cases of undoubted structural scoliosis in which 
unquestionable overcorrection was obtained? 

"2. Have you succeeded in bringing about a definite cure of undoubted 
structural scoliosis? 

"But one man in fifty has claimed without qualification to have brought about 
a definite cure of undoubted structural scoliosis. Although he was immediately 
requested to furnish the evidence and although he had volunteered to do so, 
the committee has not received it. The committee therefore concludes that of 
the fifty men who have replied to the postal card questionnaire, none are in 
possession of material evidence with which to give an affirmative answer to 
questions 1 and 2 

"Note. — Since the completion of the report the one definite and unqualified 
claim of cure in undoubtedly structural scoliosis has been retracted by letter to 
the committee." 1 

The two most careful studies of the Abbott method, apart from 
Abbott's own articles, are by Lance of Paris and Kleinberg of New 
York. The conclusions of Lance 2 were as follows: 

1( 'Am. Journ of Orth. Surg.," July, 1915, page 18. 

2 Lance: Le Traitement des Scoliosis graves par la Methode d' Abbott. Paris, 
1914. 



1 68 TREATMENT 

"In the cases where there is no marked bony lesion one can always accomplish 
correction and hypercorrection of the lateral deviation. In the cases where 
there are bony lesions in a single curve without compensatory curves, or with a 
compensatory curve not presenting deformed vertebrae, one observes this — that 
the principal curvature diminishes in all the vertebrae which are not deformed, 
and there remains a little curve of two, three or four vertebrae in height, composed 
of cuneiform and rhomboid vertebrae, and above and below at rather a brusque 
angle are formed very extensive compensatory curves. We have never been 
able to obtain more. Abbott says that he has obtained complete redressment 
and hypercorrection of scoliosis with vertebral deformity, but he has never pro- 
duced radiographs demonstrative of the fact In the very severe cases, 

where the vertebral deformities exist not only in the upper curve but on one or 
two of the compensatory curves the action is very limited, and one will only 
obtain a result very slightly marked, and which will have very slight chance 
of being maintained." 

Kleinberg, 1 from an analysis of 60 cases, reaches the following 
conclusions : 

"As might have been expected, it was found that the deformity even in its 
mildest form, did not yield rapidly to the Abbott treatment, and that it took 
months to effect any real change. Of the 60 cases, 18. . .gave up treatment, 
8 were not improved at all, and 34 were definitely made better in external 
appearance, with or without a corresponding change in the spine itself. Of 
this latter number 6 cases relapsed. This method, therefore, is applicable 
to the milder degrees of rigid scoliosis, most of which the writer has seen improved, 
though he has not yet seen any case, no matter how mild, cured, that is, trans- 
formed into one with a prefectly symmetrical back." 

Taking all this evidence which is wholly in accord with the writer's 
own experience one must fairly conclude that the situation is much 
what it was before. The method of Abbott is no cure all, and his 
claims have apparently not been substantiated by others. One has 
only to realize what Abbott's claim was to recognize its character. 
It was as follows: 2 "In a previous article on this subject 3 the state- 
ment was made that fixed lateral curvature of the spine yielded 
to treatment as easily as bowlegs or club-feet. Further experience 
has led me to believe that this deformity yields more readily than 
either of the others." 

The method of Abbott may be a little more or a little less effective 
than the suspended or prone lying positions, the scoliosis Committee 
of the American Orthopedic Association in their admirable report 
said: "It seems probable that greater degrees of correction may be 

1 "American Journ. of Orth. Surg.," June, 1914. 
2 "N. Y. Med. Journ.," Apr. 27, 1912. 
3 "N. Y. Med. Journ.," June 24, 1911. 



DISCUSSION OF METHODS 



169 



obtained with the flexed position of the spine than with the extended 
position of the spine." 

Personally the author would regard the fully flexed position as the 
one in which it was easiest to secure an improvement in body outline 
for the spine thus seems to be more flexible to manipulation and 
it may also be the position in which the greatest real correction of the 
spine is to be obtained. But although one hesitates to generalize 
from a single instance, certain doubt was thrown on the latter point 




Fig. 139. — Patient Shown in Fig. 138 after Wearing Corrective Jacket for over 
a Year. (March, 1907.) 



by an observation of the author's in which #-rays were taken of a 
boy with scoliosis in the Abbott position and in the prone lying posi- 
tion with the same amount of lateral pull. The prone position 
showed slightly more spinal correction but such an observation 
would have to be confirmed to be convincing. For the present 
we need accurate data in the way of x-rays, photographs as explained 
are misleading and impressions of little value; meanwhile the ques- 
tion must remain subjndice. 

The choice therefore must be left to the individual surgeon, the 



170 



TREATMENT 



method by rotation (Forbes) has not apparently yielded results as 
good as have the other methods, the method of side lying (Rich) 
has not been generally adopted, and the surgeon must choose accord- 
ing to his preference between head suspension, prone lying and the 
flexed position lying on the back. 

Treatment Subsequent to Application of Jacket. — Starting from the 
application of the corrective jacket two methods of treatment are 




Fig. 140. — Radiogram of a Patient Seventeen Years Old (Fig. 138) Lying on the 
Back, before the Application of Jacket. (January, 1906). — {"Jour. Am. Med. 
Assn.") 

available; (i) the original jacket may be left on or (2) after one or 
more corrective jackets have been applied a removable jacket or 
corset or brace may be used. 

(1) Permanent Corrective Jackets. — When the jacket is hardened, it 
is left solid over the parts that are made prominent by the rotation 



IT. KM. WE NT CORRECTIVE JACKETS 



171 



behind and in front, that is, in a right dorsal curve the right back 
and left front are not touched, but large windows are cut over the 
depressed side of the chest behind and the corresponding portion 
diagonallv opposite in front, so that in a right dorsal curve the left 
side would be cut out behind and the right side in front. This makes 
it possible for the depressed parts of the chest to be expanded by 
respiration, while the prominent parts are compressed. Pads of felt 




Fig. 141. — Radiogram of Same Patient as Shown in Fig. 138, Taken after the 
Application of a Plaster Jacket through Windows Cut in Front and Back of 
Jacket. (January, 1906.) — {"Jour. Amer. Med. Assn.") 

are now inserted between the prominent part of the chest behind and 
the jacket, and in the corresponding region in the front, thus making 
the jacket more corrective, and thicker pads are substituted each 
week without changing the jacket, these being drawn through with- 
out difficulty by means of a bandage. In this way, a continual 
diagonal side-pressure is kept up on the curved portion of the spine 
and is steadily increased. When these pads have become so thick 



172 



TREATMENT 



that the jacket is pushed away from the patient and no longer fits 
it will be found that it is advisable to apply a new jacket, to cut it 
out in the same way and to begin on the progressive padding. The 
use of such a permanent jacket may be continued as long as it seems 
possible to gain further correction, being changed at intervals, and 
at the end of this time a removable jacket is substituted for the 
permanent one and gymnastic treatment is begun. The removable 




Fig. 



142. — Fenestrated Jacket for Making Side Pressure by Strap. 
—(Ansel G. Cook.) 



jacket is then gradually discontinued while the patient's muscular 
condition is being improved by gymnastic exercises. 

(2) Removable Jackets. — The treatment, by removable jackets, is 
best started by the application of a forcible jacket either in recum- 
bency or suspension. This may be followed by a second forcible 
jacket at an interval of a week or so, if it seems advisable. For the 
construction of the removable jacket, the patient is suspended 
and a plaster jacket is applied which is immediately cut off to serve 
as a mold, and a forcible jacket is best applied to be worn while the 
removable apparatus is being made. The jacket which is to serve as 



CORRECTION OF TORSO 



173 



a mold is then hound together and filled with plaster of Paris and 
water, a torso thus being obtained. This torso is then remodeled by 
cutting off on the prominent side and building up on the other side, 
until it has become decidedly more symmetrical than the patient. 
It is also sawed in halves at the waist 
and set apart about an inch in order to 
secure continued extension of the trunk. 

On this corrected torso a plaster jacket 
is applied which is to be the removable 
jacket worn by the patient. This re- 
movable jacket should be supplied with 
shoulder pads, to hold the shoulders back 
in position, and should open down the 
front, being supplied with buckles and 
straps or lacings. It is generally advis- 
able to slash such jackets over the iliac 
crests in order to prevent chafing. The 
addition of 5 per cent. Portland cement 
to the plaster with which the jacket is 
made gives greater strength and dura- 
bility. This jacket is to be worn by the 
patient night and day and to be removed 
only for the exercise period, w r hich 
should consist of one hour or more 
daily, the exercises being of the type 
mentioned above. When the jacket is 
applied, it is sprung open and slipped 
on the patient, who then lies on the 
back, and the arms and legs are pulled 
on to extend the spine. It is then 
buckled tightly in place before the 
patient stands up. Such jackets may 
be made more effective by padding in- 
side of the jacket over the convexity 
of the curve with a large w r indow T cut 
on the side of the concavity. 

The Cook Strap. — The use of a broad webbing strap passing 
around the convexity of the spine and coming out of a large window 
on the opposite side of the jacket has been advocated by Cook 1 
and possesses certain advantages over padding in removable jackets 

'"Am. Journ. of Orth. Surg./' July, 1913. 




Fig. 143. — Fenestrated Jack- 
et Applied to Patient with 
Lower Dorsal Curve Strap in 
Place. — {Ansel G. Cook.) 



174 



TREATMENT 



and even in permanent forcible jackets. It is easily adjustable, gives 
a well-distributed pressure and can be varied by the position of 
the strap to attack either the rotation or side deviation. In con- 
nection with a large window on the concave side of the curve it 
furnishes a powerful means of constant correction. Cook applies 
the strap to a jacket with large windows on both sides but the writer 
has found the best use of the strap as a substitute for padding 
in jackets not in any way modified from the usual pattern. 




Fig. 144. 



-Radiogram of Patient Shown in Fig. 138 after Wearing Corrective 
Jacket for over one Year. (March, 1907.) 



Jackets of either kind should be tested for efficiency by measuring 
the height of the patient with and without the jacket. Without the 
jacket the patient places the hands on the hips and pushes up, mak- 
ing himself as tall as possible, and his height is taken in this posi- 
tion. . The jacket is then applied and the patient's height is again 
taken. If the jacket does not hold him in as good a position as esti- 
mated by the greatest height the patient can possibly assume with 



MECHANICAL OBJECTIONS 



175 



the hands on the hips, it is discarded and a more corrective one is 
made. 

If such a jacket is worn by a patient who is making good progress, 
in a few weeks from the beginning of treatment it will be found to be 
inefficient and not to be holding him on account of his improvement. 
Under these conditions the torso must be again remodeled, more cut 
away from the prominent side and greater pressure exerted. In the 




W&t 




Fig. 145. — Permanent Corrective Jacket Applied. 



course of a year, probably two or three such remodelings would be re- 
quired. These jackets may be made of leather or celluloid if preferred 
rather than plaster, but the plaster is perfectly efficient, although 
heavier. 

Mechanical Objections to All Corrective Jackets. — In applying 
force to correct the lateral curve and rotation of the scoliotic spine we 
cannot apply such force directly to the spine, but we must apply the 
corrective pressure to the ribs. The ribs are loosely attached to the 
spine, and are, moreover, rather easily distorted themselves by pres- 



176 



TREATMENT 



sure. We, therefore, must do without that direct application of 
force to the affected structure which we possess in the treatment of 
most deformities. 

Secondly, to exert effective side pressure one must be able to 
press laterally not only against the apex of the lateral curve, but to 
exert counterpressure in the other direction at the top and bottom 
of the curve, 1 and this we cannot do by pressure against the thorax 
in high dorsal curves because we cannot reach as high as the top 
of the curve. To attempt to secure a higher level of side counter- 





Fig. 146. Fig. 147. 

Fig. 146. — Remodeled Torso Ready for Application of Jacket. 

In a case of right dorsal left lumbar scoliosis which has been cut in two at the waist and 
set apart one inch, so as to increase the upward pressure on the ribs. The dark areas on left 
of the torso show where plaster has been added on the concave side to allow for correction 
of displacement and deviation. — ("J. Am. Med. Assoc") 

Fig. 147. — Front of Jacket, made over Torso Shown in Fig. 146. Note Shoulder 
Pad. — ("/. Am. Med. Assoc") 



pressure against the root of the neck is to pull against soft structures 
overlying a nerve plexus, where strong pressure is not tolerated, nor 
can side pressure be exerted on the lumbar spine, consequently cor- 
rective jackets are not satisfactory in lumbar curves or in curves 
whose apex is as high as the upper dorsal region In lower dorsal 
and dorsolumbar curves they find their best application. 

Thirdly, forcible jackets, by fixation and pressure, cause atrophy 
of the muscles of the trunk and spine, and this fact has been much 
insisted on by the opponents of the method. But when the time 
has come to begin the after-treatment, such atrophy is quickly 

X F. Lange: " Zentrlblt. fur chir. and mech. orth.," Bd. v, Hft. 12. 



FORCIBLE JACKETS 



177 



recovered from by the use of gymnastics and massage, and by 
the gradual rather than the sudden discontinuance of the support 
when the proper time comes. 

That such jackets will prove detrimental to the general health 
is a fear which is not supported by facts, for the improved posture 




Fig. 148. — Patient in Removable Jacket. Note Window on Concave Side. Jacket 
Reinforced by Steel Strips. 



and the restoration of the viscera to a more normal position are 
more than enough to counterbalance the discomfort and the handi- 
cap of the jacket, in the great majority of cases. A gain in flesh 
12 



i 7 8 



TREATMENT 



and improvement in the general condition may, as a rule, be pre- 
dicted from the application of a proper jacket. 

Finally, the danger to life from the application of jackets may 
practically be disregarded. Alarming symptoms have arisen and 
in a few instances deaths have occurred as a result, but in these 
cases the use of force has been too great. With the use of judgment 




Fig. 149. — Radiogram of Case I before Treatment by Jackets was Begun. 



and moderate force no real danger can be incurred in normal 
individuals. 

Curves due to congenital defects, infantile paralysis, rickets, and 
empyema are available for forcible correction, those from infantile 
paralysis being often among the most satisfactory in their results 
of all classes of moderate and severe scoliosis. 



RESULTS 



179 



Results. — The author's point of view with regard to results to be 
obtained has been stated under prognosis (page 127) but to make the 
matter more definite the personal experience of the author in a 
group of test cases is here given with a view of placing on record the 
x-rays of a set of cases carefully observed and personally treated. 

Six cases were selected from the Scoliosis Clinic of the Children's 
Hospital for treatment in the fall of 1914 and the photographs and 




Fig. 150. — Radiogram of Case I after Treatment by Jackets as Described 



:v-rays of these cases w T ere made under the supervision of the Scoliosis 
Committee of the American Orthopedic Association in October. In 
April these same cases were again presented to this Committee and 
their records again taken by them. These cases were under the 
personal treatment of the writer by whom all jackets were applied. 



i8o 



TREATMENT 



When it seemed advisable they were kept in the hospital for longer 
or shorter periods. Three of these cases are here presented. 

Case i. — Boy, five years old. Colored. Rachitic scoliosis, pre- 
viously treated by exercises. Right dorsal left lumbar curvature. 
Treatment was begun Nov. 23, 19 14, and ended in April. Four 




Fig. 151. — Radiogram of Case II before Treatment by Permanent Plaster 

Jackets. 



permanent jackets were applied. The patient is still under 
treatment by a removable jacket and exercises (Figs. 149, 150). 

Case 2. — Girl, eight years old, scoliosis due to infantile paralysis. 
Deformity noted in 19 10. Curve, left cervicodorsal, right dorsal, 
left dorsolumbar. First jacket Oct. 29, 19 14. Five permanent 
plaster jackets (Figs. 151, 152). 

Case 3. — Boy, eight years old, etiology not determined. Curve 



RESULTS 



181 

Four permanent 



left dorsolumbar. First jacket Nov. 9, 1914. 
plaster jackets (Figs. 153, 154). 

As the study concerned itself wholly with changes in the spine and 
not with changes in body outline only x-rays are presented, the 
photographs being omitted, which show on the whole much more 




Fig. 152. — Radiogram of Case II after Treatment by Permanent Plaster 

Jackets. 

correction than is indicated by the ac-rays. The x-rays were taken 
by the method of Bucholz and Osgood. 1 

A further case is given showing both x-rays and photographs to 
make clear the point that great change in body outline may be 
secured without much alternation in the spinal curve as shown in 
the x-rays (Figs. 155, 156, 157, 158). 

i:< Am. Journ. of Orth. Surgery," 1914, xii, 77. 



I»2 



TREATMENT 



Case 4. — Girl, six years old, curve due to rickets, deformity noticed 
when two years old. Left dorsolumbar curve treated by jackets 
since May, 191 1. First photograph Oct., 191 1, second, April, 191 5. 
Contemporaneous arrays showing that while the photograph shows 
much improvement, the spine itself has been nearly stationary. 
(Figs. 155, 156, 157, 158). 




Fig. 153. — Radiogram of Case III before Treatment by Permanent Plaster 

Jackets. 

Permanence of Results. — Successful permanent results can be ob- 
tained in hospital practice only in selected cases, the average patient 
being unable to appreciate the importance of following out the treat- 
ment sufficiently long. The criticism that such correction is not 
likely to be permanent at once presents itself. The grounds that 
lead one to suppose that retention of the growing spine in a corrected 
position over a sufficient period will lead to a change in the shape of 



RESULTS 



183 



the bones of the vertebral column and to a permanently improved 
position are as follows: 

(1) Club-foot may be cured by a similar proceeding. 

(2) The bones of the feet of Chinese women of rank are seriously 
misshapen by retention in an unnatural position. 1 




Fig. 154. — Radiogram of Case III after Treatment by Permanent Plaster 

Jackets. 



(3) Wullstein produced bony changes in dogs by a few months of 
abnormal position. 

(4) Arbuthnot Lane has 2 demonstrated that the carrying of heavy 
loads by laborers will produce changes in the bony skeleton, and that 
the changes vary according to the habitual position of the load, the 

1 P. Brown: "Jour. Med. Research," Dec, 1903. 

2 Guy's Hosp. Rep., xxviii. 



1 84 



TREATMENT 



bones subject to the greatest pressure undergoing changes in 
shape. 

(5) The fact that bone under pressure changes shape after growth 
has been reached is shown in the fact that scar tissue pressing on bone 
will cause a change in shape, 1 e.g., on the chin. 

(6) Pressure of tumors or aneurysm will cause absorption of bone. 
These facts all point to the conclusion that bone alters its shape 

under changed conditions of pressure, and that although this would 




Fig. 155. — Case IV before Treatment 
by Plaster Jackets. 



Fig. 156. — Case IV after Treatment 
by Plaster Jackets. 



be more marked during growth, the phenomenon is not unknown in 

adult life. 

It seems reasonable to hope that the maintenance of improved 

position may be expected in time to produce a change in the shape 

of the vertebrae. It is obvious that such a corrected position must 

be maintained over a period of many months to secure permanent 

results. Schanz 2 has provided clinical evidence that his results have 

been permanent in the time during which they were observed. 

1 Ziegler: Pathology, English ed., 1896, ii, 146. 

2 "Verhdlg. d. Deutsch. Ges. f. orth. Chir.," 1908, page 57. 



GYMNASTICS 



l85 



Choice of Methods. — The choice between the use of fixed or re- 
movable corrective jackets must be determined by the circum- 
stances of the patient, the temperament of the child, and similar 
considerations. Careless hospital patients will do better in a fixed 
jacket for a year or two, while nervous girls in private practice will do 
better in split jackets. 




Fig. 157. — Radiogram of Case IV before Treatment by Permaxext Plaster 

Jackets. 

Gymnastics Following Forcible Correction. — So soon as the final 
corrective jacket has been removed and replaced by a removable 
one, gymnastic treatment should be begun. The exercises to be used 
have been described in the section on Gymnastics. Such treatment 
to accomplish results must be given from one to four hours a day for 
a period of at least six months from the removal of the final corrective 



i86 



TREATMENT 



jacket, after which less frequent and vigorous exercises may be suffi- 
cient. Exercises must be continued until the corrected position is 
maintained without apparatus from month to month, and the 
supporting apparatus discontinued at first for short periods, gradu- 
ally increasing in length. The length of time that active treat- 
ment must be continued will depend on the age of the child, the 




Fig. 158. — Radiogram of Case IV after Treatment by Permanent Plaster 

Jackets. 

severity of the case, the efficiency of the treatment, and similar 
factors, but any case of scoliosis severe enough to require forcible 
correction will not, as a rule, occupy less than two years, and often 
a longer period. 

The present discredit of gymnastic retentive treatment is due to its 
use in too small dosage and to a failure to appreciate that a problem 



OPERATIVE TREATMENT 



187 



so grave as the permanent maintenance of the corrected position 
in a spine, which has suffered some degree of bony distortion, is 
only to be obtained by a long continuance of accurate and mechan- 
ically sound treatment. 

Operation. — The question of the operative relief of scoliosis has 
been for the present abandoned. An operation was proposed by 




Fig. 159. — Boy Aged 12, before 
Treatment. — ("J. Am. Med. Assoc") 



Fig. 160. — Boy'Aged 14, after Two 
Years' Treatment by Means of Per- 
manent Jackets (see Fig. 159). 



Volkmann 1 in 1889, consisting of resection of the ribs on the convex 
side of the curve, and this operation was also performed by Casse 2 
and Hoffa 3 with fair results. A similar operation was thought out 
by N. M. Shaffer, of New York, about fifteen years ago, and spoken 
of to the writer at that time but never put on record, as the general 
surgeons to whom it was referred refused to sanction it. 4 

A good operative correction has been obtained by Hoke, 5 of 
Atlanta, Ga., who resected the ribs on the convex side of a girl of 

1 Volkmann: "Berl. klin. Wochens.," 1889, 50. 

2 Casse: "Bull, de l'Acad. Royal de Med. de Belgique," Dec. 30, 1893; «Jan. 
27, 1894. 

3 Hoffa: "Zeitsch. f. orth. Chir.," 1896, 401. 

4 Shaffer: "Amer. Surg. Bulletin," Jan. 1, 1894. 

5 Hoke: "Amer. Jour, of Orth. Surg.," i, 2. 



i88 



TREATMENT 



nineteen and lengthened those of the concave side in a severe dorsal 
curve. By the application of a corrective jacket great improvement 
was obtained. 

Jaboulay 1 divided the cartilage of a single rib with a view of im- 




Fig. 161. — Girl Aged 16, before Treatment. — ("J. Am. Med. Assn.") 

proving the shape of the thorax. Bade 2 has reported a case where he 
resected the ribs, but cautions against the use of narcosis in severe 
scoliosis. 



1 Jaboulay: "Prog. Med..'" Nov., 1S93. 

2 Bade: "Klin. Mittheil." in Centralbl. f. Chir./' 1903, 38, 1045. 



TREATMENT 



189 




Fig. 



[62. — Girl Aged 18 after Two and a Half Years' Treatment by a Series of 
Permanent Corrective Jackets. See Fig. 161. — ("/. Am. Med. Assn.") 



190 



TREATMENT 




Fig. 166. Fig. 167. 

Figs. 163-167. — History of a Case of Scoliosis from 1903-1910. 

Increase under gymnastics and imperfect jacket treatment. 



Figs. 163, 164. — 1903-5. 

Figs. 164, 165. — -1905-7. 

Figs. 165, 166. — 1907-9. 
jacket. 

Figs. 166, 167.— 1909-10 



only a mild brace was possible with no gymnastics 



Treatment by jackets (one forcible) and gymnastics. 

Left clinic and had gymnastics twice a week outside with no 

Returned to clinic but heart displacement was so great that 



CHAPTER XIV 

FAULTY ATTITUDE 

NORMAL ATTITUDE 

In addition to curves to the side in the spinal column, which have 
been described as scoliosis, there are modifications of the normal 
forward and backward spinal curves which demand consideration. 
Although it is comparatively easy to say whether or not a patient is 
normally symmetrical when seen from the back it is not so easy to say 
whether or not a given attitude as seen from the side is normal because 
there is no generally accepted normal attitude in the standing human 
figure as seen from the side. It is necessary first to consider those 
facts which are known with regard to the normal attitude before 
passing on to analyze its abnormalities. Normals have been de- 
scribed by Weber, Meyer, Langer, Parow, Henke, Staffel and others, 
which differ much among themselves as would have been expected, 
from the lack of a uniform or satisfactory system of measurement 
and also because the standing position is influenced by sex, age, 
race and occupation. 

As the problem is one of balance from the feet up, it is evident that 
any reliable method of analysis must take into account the base of 
support and the line of gravity in order correctly to represent the 
normal standing position as seen from the side. Merely to draw a 
spinal outline and construct an ideal figure without regard to the 
relation of such spinal curve to the legs or base of support is mis- 
leading. One has only to read the appended literature to realize 
that we have no reliable normal of the standing position as seen from 
the side. 1 

1 Borellius, J. A.: "De Motu Animalium, Lugduni Batavorum," 1679. 

Braune, W., and Fischer: "Ueber den Schwerpunkt des menschlichen Korpers, 
Abhandl. d. k. Sachs.," "Akad. d. YVissensch., Math.-physik Klasse," Leipsic, 
1889, xv, 7. 

Dickinson, R. L. : "The Corset; Questions of Pressure and Displacement," 
"New York Med. Jour.," Nov. 5, 1887. 

Duchenne: "Etude physiologique sur la courbure lombo-sacree et de l'inclina- 
tion du bassin pendant la station verticale," "Arch. gen. de med.," series 6, viii, 
534- 

Goldthwaite, J. E.: "The Influence of Pelvic Joints on Posture," "Physical 
Education Rev.," June, 1909. 

191 



192 FAULTY ATTITUDE 

A new method of record which promises to enable one to analyze 
the normal standing position and its abnormalities is that of Reynolds 
and Lovett, 1 but until a very large number of normal studies have 
been made, no reliable statement of what the normal really is, can 
be made, and no very accurate information can yet be given of 
variations from the normal in this plane. This method gives a side 
elevation of the erect standing position of the individual, with at 
the same time, the position of the line of gravity in its relation to 
the body and to the base of support. 

On the platform of a dial scale registering up to 100 pounds is placed a sharp 
edge which supports one end of a flat board (B), the other end of which is sup- 
ported by a similar sharp edge placed on a rigid block (C). The distance be- 
tween the edge is 508 mm. (20 inches). A short distance behind the rigid block 
is placed an upright post (E) with a horizontal sliding arm (D, shown in section 
only), which furnishes a plane of reference from which the antero-posterior 
position of each of the important landmarks of the body can be determined by 
measuring their horizontal distance from this sliding arm (Fig. 168). 

The determination of the antero-posterior position of the center of gravity 
in the standing subject is made as follows: 

Goldthwaite : "The Relation of Posture to Human Efficiency," Borton: 
"Med. and Surg. Journal," Dec. 9, 1909. 

Gerdy: "Determination des levriers que forment la colonne vertebrale, les 
femurs et les tibias dans l'attitude verticale," "Rev. med.," 1834, 323. 

Horner, F. : "Ueber die Krummung der Wirbelsaiile im aufrechten Stehen," 
"Inaug. Diss. Zurich," 1854. 

Kellogg, J. H. : "Experimental Researches: Relation of Dress to Pelvic Dis- 
eases of Women," "Tr. Mich. State Med. Soc," 1888. 

Kellogg, J. H. : "The Relation of Static Disturbances of the Abdominal Viscera 
to Displacements of the Pelvic Organs," "Proc. Internat. Periodical Cong. 
Gynec. and Obstet.," 1892. 

Kohlrausch, E.: "Physik des Turnens Hof.," 1887, page 17. 

Lane, W. Arbuthnot: "Lancet," London, Nov. 13, 1909. 

Meyer, G. H. : ' 'Die Statik und Mechanik des menschlichen Knochengeriistes," 
Leipsic, 1873. 

Mosher, Eliza M.: "The Influence of Habitual Posture on the Symmetry and 
Health of the Body," "Brooklyn Med. Jour.," July, 1892. 

Mosso: "Application de la balance a l'etude de la circulation chez l'homme," 
"Arch. ital. de biol.," 1884, v. 131. 

Parrow, W. : "Studien iiber die physikalischen Bedingungen der aufrechten 
Stellung und der normalen Krummungen der Wirbelsaiile," "Virchows Arch. f. 
path. Anat," 1864, xxxi, 74. 

Schmidt: "Unsere Korper," 1903, page 63. 

Staffel, F. M.: "Die menschlichen Haltungstypen und ihre Beziehung zu den 
Ruckengratsverkriimmungen," Wiesbaden, 1889. 

Taylor, C. Fayette: "Spinal Irritation, or the Causes of Backache among 
American Women," New York, William Wood and Co., 1870; "Tr. Med. Soc, 
New York," 1864. 

Weber, M. and E.: "Mechanik der menschlichen Gewerkzeuge," Gottingen, 
1836. 

1 Reynolds, E., and Lovett, R. W.: "Method of Determining the Position of 
the Center of Gravity in Its Relation to Certain Bony Landmarks in the Erect 
Position," "Am. Jour. Physiol.," May 1, 1909; "Jour. Am. Med. Assn.," Mar. 
26, 1910. 



ANALYSIS OF IPIUOltT POSITION 



193 



The subject is weighed on an ordinary set of scales. He is then placed on the 
balance plane (B) at a known point facing the scales. (The exact point is un- 
important, but after experimentation there was selected as most convenient that 
in which the heels are situated at one-fourth the length of the plane from the 
posterior sharp edge.) A removable ledge (F) against which the heels are placed 
is provided here. 

Since the balance plane on which the subject stands acts as a lever, in which 
the weight is borne between the fulcrum (the posterior sharp edge) and the sup- 
porting force (the spring which governs the scales), it is evident that the weight 
recorded on the dial (the balanced weight) will bear to the total weight the same 
proportion as that which obtains between the total length of the balance plane 
and the distance between the perpendicular dropped from the patient's center 
of gravity and the posterior end of the plane. That is: As the total weight is to 




^ 



IS 



D 



Fig. 168. — Diagram of the Apparatus for Estimating the Center of Gravity. 

A, scale; B, balance plane on which patient stands facing A; C, block supporting triangular 
edge; D, movable horizontal arm on upright for obtaining horizontal distances; E, vertical 
upright for standard plane; F, ledge against which heels are placed. — (''American Journal 
of Physiology.") 

the balanced weight, so is the total length of the board to the horizontal distance 
of the center of gravity of the patient from the posterior sharp edge (the ful- 
crum), or, to illustrate by a specific instance: The subject's total weight is 140 
pounds; when placed on the balance plane his weight is 50 pounds, and the total 
length of the board is 20 inches. 
The formula reads then: 

140 _ 20 
50 ~ x 
This is then worked out as follows: 

140)1000(7.1 
980 
200 
The center of gravity of the subject then lies perpendicularly above a point 
7.1 inches forward from the posterior sharp edge. 
13 



194 



FAULTY ATTITUDE 



After the determination of the position of the center of gravity, which should 
occupy on an average one or two minutes, the position of the following points 
which have been marked on the skin are measured and recorded. 




Fig. 169. — Apparatus in Use. The Lines Drawn Represent the Lines Shown in 
the Record Tracings. The Long Line Running Vertically is the Perpendicular of 
the Center of Gravity. — ("J. Am. Med. Assn.") 

1. The position of the back edge of the malleolus. 1 

1 In this and the following determinations the horizontal difference is obtained 
by a footrule, one end of which is placed against the marked point, while the body 
of the rule is held by the thumb against the upper surface of the sliding arm. 
Since this surface (and therefore necessarily the rule) is horizontal, the height of 
the point observed may be read at the same time, from a graduated scale which 
is marked on the upright post. 



NORMAL ATTITUDE 



195 



The position of the back of the head of the fibula. 

3. The position of the middle of the trochanter. 

4. The position of the posterior part of the spine of the fifth lumbar vertebra. 

5. The position of the posterior part of the spine of the seventh cervical 
vertebra. 

All these points are taken under the usual conventions of somatologic measure- 
ments on the living. 

The measurements having been recorded, are then easily translated into 
graphic form by the reproduction of the observed measurements on a sheet of 
paper, of which the bottom represents the balance plane 
and the edge of the paper the posterior plane of 
measurement. 

These five comprise all the exact measurements which 
are taken, but since the value of their graphic represen- 
tation is considerably enhanced by its combination with 
some sort of representation of the body profile of the in- 
dividual, we have completed the examination by the 
use of a device which obtains this with fair accuracy 
and which is illustrated in Fig. 169. 

A series of horizontal metal arms, tipped with cellu- 
loid, slide easily through holes in the vertical wooden 
arm. These metal arms are shaken out to their full 
length, and their ends pushed rapidly and lightly against 
the subject's back in the median line, the point of the 
uppermost horizontal arm being applied to the seventh 
cervical vertebra. In the ' construction of the graphic 
record (Fig. 170), the position of this profile is known 
by its relation to the seventh cervical and fifth lumbar 
vertebrae; that is, these points are marked on the paper 
from the measurements taken, and the end of the upper- 
most arm of the profile instrument is laid against the 
mark which represents the seventh cervical, while a 
lower point is in contact with the mark representing the 
fifth lumbar vertebra. The curve is then traced on the 
paper containing the other measurements from the ends 
of the pins throughout its length. 

The body curve of the ventral surface is obtained in 
the same way. The uppermost arm of the profile in- 
strument is applied to the anterior surface of the neck at 
the level of the seventh cervical vertebra. The position 
of this curve on the chart is ascertained by using as points of reference the 
horizontal distances between the posterior parts of the seventh cervical and 
fifth lumbar vertebrae and the points horizontally opposite on the ventral 
surface, measured on the subject by a pelvimeter or other calipers. 

It would be very desirable that this graphic record should be completed in 
every instance by a representation of the inclination of the brim of the pelvis, 
which would, of course, include its relation to the trochanter, but after much 
experimentation we have been unable to measure with accuracy the inclination 
of the pelvic brim in the living subject. 



Fig. 170. — Record 
of the Normal Posi- 
tion AND THAT IN- 
DUCED by High-heeled 
Shoes, the Normal in 
Solid Line, the In- 
duced Position in 
Dotted Line. — ("J. 
Am. Med. Assn.") 



196 FAULTY ATTITUDE 

The use of the profile curves in the graphic representation involves the dis- 
advantage that the chart must be drawn life-size, but it can be reduced later by a 
pantograph to any desired size. 

The sources of error incident to the method are swaying of the subject, errors 
in measurement from the vertical plane, distortion of attitude during observation, 
inaccuracy in locating on the skin the bony landmarks selected, varying position 
of the feet, horizontal rotation of the pelvis and psychical influences. These 
errors and their prevention are dealt with at some length in the original descrip- 
tion of the method. 



So far as the observations by this method have gone they show that 
in the erect position the center of gravity of the body lies in front of 
the ankle-joints, which are held from dorsal flexion in this position 
by the gastrocnemius muscles. The center of gravity lies also in 
front of the knees, which are similarly held in position by the ham- 
string and quadriceps extensor muscles. The center of gravity 
lies also anterior to the sacro-iliac joints and most of the vertebral 
joints. The position of the acetabula cannot be determined in the 
erect position in the living individual because we have no means 
of locating them from any available landmarks. If we were able 
to determine the position of the acetabula in the antero-posterior 
plane it would be possible to state definitely, from the relation of 
the center of gravity to them, whether the trunk in the erect position 
would tend to fall forward or backward at their level. But from 
the impossibility of obtaining definite data on this point we are 
obliged to resort to another line of observations to determine this 
matter. 

It has been shown by many experiments that when the cadaver is 
stood erect and the legs and ankles are fixed (to prevent the cadaver 
from collapsing on the ground), the trunk falls forward from the hips. 
In the erect position then, the trunk is held extended on the legs by the 
combined and continued action of the posterior musculature, the chief 
factors here being the hamstrings, the glutei and the erector spinae 
muscles. 

After a consideration of this theoretical side of the subject which 
will in time enable us to obtain exact information as to abnormalities 
of the standing position it becomes necessary to formulate our 
present knowledge with regard to these abnormalities. 

When the antero-posterior and lateral variations coexist, as 
frequently happens, the lateral variation is in general considered the 
more important one, and the case is classed as scoliosis. 



ROUND SHOULDERS 
ROUND SHOULDERS 



197 



Stoop or slant shoulders, round back, round hollow back, stoop- 
ing, faulty attitude, kyphosis, bowed back. 

German — Schlechte Haltung, runde Riicken, Kyphose, hohlrunde 
Rucken, kypholordose, habituelle Kyphose. 

French— Dos Voute, Cyphose. 

Italian — Schiene rotonde. 




Fig. 171. — Round Back with Flat Chest and . Prominent Abdomen. 

Grouped under this name are various types of faulty attitude. 
Variations from the normal antero-posterior attitude are in general 
grouped under the name of round shoulders. These shade into each 
other and are characterized by a disposition to economize muscular 
force in maintaining the erect position. These deviations have in 



ICjo FAULTY ATTITUDE 

general been grouped as round shoulders because an increased con- 
vexity of the dorsal spine is the most common characteristic. 

In general the attitude is familiar, the head is carried forward and 
is somewhat flexed, the physiological curve in the dorsal region is 
increased and the dorsal region unduly prominent behind, in which 
backward curve the lumbar region may share, or there may be also 
an increased lumbar curve forward. The shoulders are drooping 
and the chest narrow and flat, while the scapulae behind are promi- 
nent on their posterior borders and the inferior angles may stick 
out markedly (scapulae alatae). The abdomen is prominent, es- 
pecially in its lower part. Flat-foot or pronated foot frequently 
coexists. 

Children with round shoulders are, as a rule, below the average in 
muscular development and lack vigor; they are clumsy in their move- 
ments and walk heavily. In some cases the deformity can be re- 
moved by a muscular effort on the part of the patient or by gentle 
pressure with the hands, but in most cases of even average severity 
the deformity cannot be wholly corrected by gentle passive force, as 
the maintenance of the malposition has led to adaptive shortening of 
the soft parts concerned. The cases may, therefore, be considered 
as flexible or resistant, an important distinction in treatment. Great 
injustice is done to children with resistant round shoulders by the 
continual commands to "sit straight," a position which it is im- 
possible for them to assume. 

If such a child is laid face downward on a table with the arms at 
right angles to the body the arms may by passive force be carried back 
of the middle line of the body. If in this position the arms are 
carried up beside the head and then lifted back they cannot as a 
rule be carried so far as the median plane of the body. If such a 
child is told to put the arms up in the air in the standing position, it 
is done by making the back hollow in the lower part and protruding 
the abdomen, because the soft parts between the chest and arms 
have become contracted and do not permit a free movement. 1 
Lateral curvature of the spine frequently coexists. 

The affection is not wholly one of the spine, but implies a disturb- 
ance of relations from the feet upward because an increase in the 
backward curve of the spine implies a forward curve or forward dis- 
placement somewhere else to balance it. The dorsal spine in other 
words cannot become more convex without a compensating lumbar 

1 E. H. Bradford: " Round Shoulders," "Orth. Trans.," vol. x, page 162. 



ROUND BACK 



IQ9 



curve forward, or a forward displacement of the pelvis and legs if the 
lumbar spine is involved in the backward dorsal curve. 

Round shoulders, therefore, is not to be considered or treated as 
an affair wholly concerning the dorsal spine and shoulders. On 
closer analysis these cases will be found to fall into four not very well- 
defined groups. Transition cases of all grades are seen, and the 
division is mentioned simply to aid in the study of the cases and their 
treatment. The groups are as follows: 




Fig. 172. — Round Back. 



i . Round Back. — The dorsal and lumbar spine form one convexity 
backward, which is physiologically a persistence of the infantile 
position (page 21). A lordosis is apparently of ten present, but on 
identifying the landmarks this will be found to be merely the up- 
ward and forward slope of the sacrum and that the lumbar spine 
does not share in it. 

2. Round Hollow Back. — The dorsal spine is bowed backward, 
but the lumbar spine is bowed forward. The appearance of round 
shoulders is present, but the general attitude is modified because the 



200 



FAULTY ATTITUDE 



pelvis apparently has a greater inclination than in round back, the 

abdomen is prominent, and the gross appearance is the same as in 

round back (Fig. 173). 

3. Round Upper Back.— In certain cases the dorsal backward 

curve occurs in the upper part of the spine and gives an especially 

noticeable forward thrust to the 
head and a prominence between 
the scapula?. These cases are 





Fig. 173. — Round Hollow Back. 



lA 



Fig. 174. — Round Upper Back. 



J 



rather likely to be rigid and respiratory capacity is poor. The 
lumbar physiological curve is not necessarily abnormal (Fig. 174). 
4. Flat Back. — In certain cases the vertebral column is flat and 
has apparently nearly lost its dorsal and lumbar physiological curves. 
The pelvic inclination is obviously diminished and a frequent associa- 
tion with this attitude is a forward resistant position of the shoulders. l 
This forward position of the shoulder girdle may, however, ac- 



x Hasebrook: "Zeitsch. f. orth. Chir.," xii, 4, 613. 



ETIOLOGY 20I 

company other forms of antero-posterior deviation, such as round 
back. 

In certain cases as noted by Haglund 1 the back is rounded from 
side to side without especial kyphosis. 

It must be recognized how very superficial and unsatisfactory this 
classification is and it must be evident that we are a long way from 
recognizing the essentials which cause this condition. For purposes 
of discussion these four divisions will still be spoken of as round 
shoulders in spite of the fact that this is merely one expression of 
faulty antero-posterior attitude which involves the whole body from 
the base of support to the head. 

ETIOLOGY 

The shape of the figure is as characteristic of the individual as the 
form of the features and some children inherit straighter spines than 
others. A certain amount of importance must therefore be attached 
to the type of spine with which the child starts. Further evidence 
of a congenital origin of round shoulders than this (except in gross 
congenital lesions of the spine), is on the whole wanting. 

In general the causes of round shoulders are to be sought in — (a) 
conditions causing muscular weakness; (b) conditions causing a flexed 
position of the spine for long periods, and in (c) overweighting of the 
shoulders by improperly arranged clothing; (d) rickets. Some 
German writers incline toward the view that a weakness of the will 
is a more important cause than weakness of the muscles. 

a. Conditions causing muscular weakness are found in rapid 
growth, overwork and bad air at school, improper school furniture, 
acute illness, bad hygiene at home, and similar conditions. 

b. Prolonged flexion of the spine is induced by school furniture 
which fails to support the back, by errors in vision which necessitate 
stooping over the books in reading, and in careless attitudes of reading 
and sitting permitted at home. The child with normal eyes should 
not have to hold the book nearer than twelve to fourteen inches. 

c. The customary method of supporting a child's clothes in this 
community consists in the use of a waist, loose around the abdomen, 
to which drawers and skirts or trousers are buttoned. 2 To this waist 
are also attached side elastic stocking supporters which are kept tight 
to prevent the stockings from wrinkling. This waist is supported 

1 Haglund: "Zeitsch. f. orth. Chir.," xxv, 649. 

2 Bradford: "Orth. Trans.," vol. x, 162; Goldthwait: "Amer. Jour, of Orth. 
Surg.," vol. i, 64. 



202 



FAULTY ATTITUDE 



above by two shoulder-straps passing over the shoulders near their 
tips. The whole weight of the clothes and the added pull of stout 
elastics is thus transferred to the child's movable shoulders, of all 
parts of the body the least suited to hold against a steady downward 
pull. This pull is transferred in a measure to the spine by the 
muscles, clavicles, and thorax, and tends to produce flexion. 

The remedy of this condition 

consists in supporting as much as 

possible the clothing from a belt, 

! using round garters, or in cases 




Fig. 175. — Flat Back; Forward Posi- 
tion of the Shoulder-girdle. 



Fig. 176. — Waist with Garters Pull- 
ing Shoulders Down and Forward. 



with markedly prominent abdomens the use of the corset waist to 
be described. 

OCCURRENCE 



In examinations of school children the observers find antero- 
posterior curves less frequent than lateral, but as before explained it 
is often impossible to say what is an antero-posterior curve and 
what is a normal. 

At Stockholm, Haglund found, in 1599 children, 280 scolioses and 
170 antero-posterior curves "(90 boys and 80 girls). 



PROGNOSIS 203 

The Lausanne series of 2314 children showed 571 scolioses (24.6 
per cent.) and 135 antero-posterior curves (5.8 per cent.), with 47 
combined cases included in the above. 

Gronberg found 715 antero-posterior curves in 8250 Finnish 
children. They were divided as follows according to his classification : 
Kyphosis (round back), 478 (66.9 per cent.). 
Kypho-lordosis (round hollow back), 149 (20.8 per cent.). 
Lordosis (hollow back), 88 (12.3 per cent.). 
The age of occurrence of round shoulders Covers the period of 
childhood from shortly after the time that walking begins to adoles- 
cence; most cases are seen by the surgeon in middle childhood and 
about puberty, when in girls especial attention is paid to the figure 
and carriage. 

PATHOLOGY AND MECHANISM 

The pathological changes in round shoulders must be determined 
rather by inference and interpretation of clinical symptoms than by 
postmortem examination. 

Permanent kyphosis in a healthy growing dog was produced ex- 
perimentally by Wullstein, who approximated the pelvis . and 
shoulders by straps, causing a flexed position of the spine. In 
children who continue to grow with the spine in flexion, analogous 
adaptive changes must occur in the spine and its surrounding struc- 
tures to those found in scoliosis. 

Hasebrook 1 considered the cause of resistant forward displace- 
ment of the shoulders to lie partly in the costoclavicular and coraco- 
clavicular ligaments and partly in the pectoralis and serratus muscles. 
He divided the cases into two groups — first, those due to contrac- 
tion of the muscles holding the shoulders forward, and, second, to 
weakness of the muscles holding them back. In certain cases, 
however, it is due to malformation of the upper part of the scapula? 
which prevents their approximation to the middle line behind. 

PROGNOSIS 

The attitude of round shoulders is not to be regarded as one which 
will be spontaneously outgrown. On the other hand, it requires 
treatment, and with adequate treatment and proper hygiene the 
prognosis for recovery is good in young children. In older children 
and adolescents improvement and perhaps cure are to be ob- 

l " Zeitsch. f. orth. Chir.," xii, 4, 613. 



204 FAULTY ATTITUDE 

tained. Even in young adults an improved position of the shoulders 
and a better expansion of the chest are to be secured by adequate 
treatment. 

If the attitude of round shoulders is allowed to persist into adult 
life there are certain respects in which it may affect unfavorably the 
health of the individual. The flat chest and diminished chest 
capacity mean impaired respiratory capacity, and diminished room 
for the heart, and the large abdomen favors ptosis of the abdominal 
viscera, both factors leading to impaired efficiency. 1 Moreover, the 
bowed spine is generally a weak spine and such patients are liable 
to static backache, 2 that is, a backache due to strain of the posterior 
muscles described under the names of " hysterical spine," " irritable 
spine," etc. 

DIAGNOSIS 

The diagnosis of round shoulders, when it is present in any marked 
degree, as a rule, presents no difficulty, but at times it is not easily 
distinguished from more serious affections, causing a backward bow- 
ing of the spine. The means of distinguishing between the different 
varieties of round shoulders have been sufficiently indicated in the 
description of them. The important point is to distinguish a static 
bowing of the spine from one caused by disease. In the former there 
is no marked stiffness of the spine, pain is absent, the bowing is 
gradual, and x-ray appearances are normal. 

Differential Diagnosis. — Pott's disease (tuberculosis of the spine, 
angular curvature of the spine) was discussed in speaking of the diag- 
nosis of scoliosis. At certain stages of dorsal Pott's disease the 
attitude may resemble round shoulders. Arthritis deformans of the 
spine was discussed under the diagnosis of scoliosis. 

No gymnastic treatment for a case of round shoulders should be 
undertaken in a patient where pain or stiffness of the back is present 
without a very careful preliminary period of observation and a 
careful elimination of the first two conditions mentioned above. 

TREATMENT 

The treatment of round shoulders is different in flexible or non- 
resistant cases and in resistant cases. 

Non-resistant Round Shoulders (Flexible Round Shoulders). — 
The treatment does not differ radically from that of postural sco- 

1 Goldthwait & Brown: "Am. Journ. of Orth. Surgery," Nov., ion. 

2 Reynolds and Lovett: Loc. cit. "Journ. Med. Assoc," Mar. 26, 1910. 



TREATMENT 



205 



liosis in that both are of the type of the " setting-up drill" of the 
army recruit. In both, one tries to substitute a correct attitude for 
the incorrect or faulty one. What has been said with regard to the 
treatment of postural or functional scoliosis applies to the treatment 
of flexible round shoulders, the routine and exercises being described 
in that place (140) for both conditions, and certain exercises being 
being designated as especially adapted to round shoulders. 

Resistant Round Shoulders. — The treatment of these cases is 
similar in plan to that of structural scoliosis where first mobilizing 






Fig. 177. — Apparatus for Stretching Round Shoulders and for the Application of 

Forcible Jackets. 



and then retentive measures must be separately recognized, even 
if both are carried out simultaneously. 

Mobilization. — When the shoulders are held forward by contrac- 
tion of the soft parts and cannot easily be replaced in the normal 
position, simple gymnastics are likely to prove unsatisfactory and 
some stretching of the contracted parts is necessary in order to save 
time and make gymnastics more effective. To stretch these soft 
parts by gymnastic exercises is slow and often unsatisfactory, and 



206 FAULTY ATTITUDE 

when it is done must be accomplished by passive stretching, induced 
by pulling back the shoulders either with the arms at the sides or 
on a level with the shoulders, whichever position offers the greatest 
resistance. 

Passive stretching, however, by means of an apparatus is more 
efficient and quicker. The means to be described offers a simple 
method. 

The apparatus consists of an oblong gas-pipe frame of the ordinary pattern. 
Fastened to this near the middle, and hinged so as to be raised to any degree, is 
another section of gas-pipe lying on the frame proper and of the same shape and 
size as the upper half of the frame. To this movable section is fastened, at right 
angles to it, and movable on it, a gas-pipe bridge rising about eighteen inches from 
the movable section (Fig. 177). 

When prepared for use two strips of webbing, lying one over the other, run 
from each of the buckles at the bottom of the frame. The lower two strips are 
tightly drawn, and run to the buckles at the end of the movable section. The 
upper two are loosely fastened to the bridge over the movable section. The cross- 
pieces are tightened and the patient laid face downward on the webbing strips, 
which may, if desired, have laid over them, a folded piece of sheet wadding. The 
strips, however, even in adults, are not uncomfortable. The thighs are flexed 
and the feet rest on the floor, so that the lumbar spine is flattened. Two pieces 
of webbing are passed over the mid-dorsal region from side to side, tied to the 
lower non-movable frame on each side. These furnish the resistance for the 
straightening of the spine when the upper end of the frame is lifted, carrying with 
it the head and upper chest. The upper part of the frame is lifted after the 
patient is in place and as much force as seems advisable is exerted. This should 
never be pushed beyond the point of mild discomfort. Several stretchings are 
first made of a few seconds each, and the movable part of the frame again let 
down to rest the patient. 

Forcible Correction. — In average cases intermittent stretching is 
sufficient to loosen up the contraction and to make an improved 
position possible. In the severer c^6es, however, a plaster jacket 
should be applied in the improved position. 

The patient's spine is hyperextended as described, by raising the 
movable part of the frame, which is then fastened in this position and 
a plaster-of-Paris jacket applied, including the shoulders, which must 
be well padded by felt on their anterior surface. This jacket holds 
the dorsal spine somewhat extended 1 and the shoulders back, by firm 
pressure, and the pressure can be increased from day to day by in- 
serting more felt between the jacket and the shoulders. 

Such jackets should be worn from two to four weeks, and on their 
removal efficient gymnastic work begun, supplemented by braces, if 
necessary, to hold the improved position between treatments. 

1 R. W. Lovett: "Amer. Jour, of Orth. Sur.," ii, 2, 200. 



TREATMENT 207 

The use of corrective or retentive braces in round shoulders is often 
unsatisfactory because they are, as a rule, constructed only to pull the 
scapulae and arms backward, without making efficient forward pres- 
sure on the curved dorsal spine or making any marked improve- 
ment in the general attitude. The " shoulder braces " sold in the 
instrument shops are notably unsatisfactory in most cases. 




Fig. 178. — Corset- waist for the Treatment of Round Shoulders. 

In flexible cases of moderate grade or in rigid cases of the same 
degree which have been made flexible, a properly constructed corset- 
waist to support the abdomen has, in the experience of the writer, in 
many cases proved more satisfactory than a brace in inducing an im- 
proved attitude. The abdominal element in these cases has been 
too much overlooked and the relaxed and stretched abdominal wall is 
a very important feature of the symptom- complex roughly called 
"round shoulders." 



208 



FAULTY ATTITUDE 



Efficient abdominal support by means of a corset-waist not only 
'enables the stretched abdominal muscles to shorten and recover 
tone, but by supporting the abdominal contents enables the patient 
to assume a better general position. A better position of the thorax 
at once becomes easier and the whole attitude is improved. 




Fig. 179. — Round Shoulders before 
Forcible Correction. 



Fig. 180. — Round Shoulders after 
Treatment Following Forcible Cor- 
rection. See Fig. 153. 



Such corset- waists should fit tightest around the bottom just 
above the trochanters and should diminish in pressure from below 
upward, the upper part of the abdomen being free from constriction. 
They should button in front but be laced in the back, and from them 
may be hung skirts and stockings. 

There is no objection to their use in young children and the fear of 
the parents that they will " weaken" the abdominal wall will be dis- 
pelled as soon as the improved abdominal outline is seen after a short 



TREATMENT 209 

use of them. They should be used, of course, only in connection with 
and accessory to gymnastic treatment (Fig. 178). 

Corsets and Braces. — The use of supports to maintain the spine in 
a correct position is indicated — (1) in the case of children with lax 
muscles who are unable to hold an erect position between gymnastic 
tieatments; (2) after forcible correction to retain what has been 
gained; and, (3) in resistant cases which are being stretched; but 
which cannot maintain between stretchings the improvement se- 
cured by each one. In all of these the brace is to be regarded as a 
temporary measure, supplementary to the other treatment, whether 
gymnastic or mobilizing, and to be given up as soon as it can be dis- 
pensed with. As the sole treatment of resistant round shoulders 
the use of a brace, which by its corrective effect is to cure the 
malposition, is not to be advised. The brace which, on the whole, 
is the most generally effective is the tempered steel upright support. 
It is made as follows: 

This form of apparatus consists of (a) a horizontal pelvic band, (6) two up- 
rights, and (c) a cross-bar. 

a. The horizontal pelvic band encircles the posterior part of the pelvis from 
a point one inch posterior to the anterior superior spine on one side to a similar 
point on the other side. It is curved to fit the contour of the pelvis and should 
lie close against it. It is made of No. 15 gauge sheet steel, one and one-eighth 
inches wide. The uprights run from the posterior pelvic band along the sides 
of the spine to a point about on a level with the acromion process. At this point 
they are curved outward on the flat, on an angular turn, at an angle of forty-five 
degrees or more, and run upward and outward to a point just behind the anterior 
border of the trapezius. In this upper part they are curved to fit the contour of 
the shoulders and should lie flat against the skin when the axillary straps are 
tightened. 

b. The uprights at their lower part are farther from each other than they are 
at the top. At the bottom their outer edges should be separated by a distance 
somewhat less than the distance between the two posterior superior spines. At 
the top they should lie over the transverse processes. They are made of No. 16 
gauge sheet steel, five-eighths of an inch wide, and should follow the outline of the 
back in general, but whatever correction is desired in the standing position is to 
be made by bending the uprights to fit the curve of the back in a corrected 
position rather than in the faulty position. 

c. The cross-bar consists of a piece of steel, which in length should be one 
inch less on each side than the breadth of the body at the level where it is placed. 
It is riveted transversely to the uprights at a point just below the posterior fold 
of the axilla. The projecting ends beyond the bars should not rest on the 
scapulae, but, if necessary, should be set backward by an angular curve to clear 
the scapulae. These are made of the same material as the uprights. 

Buckles are placed on the ends of the pelvic band, and the cross-bar and 
axillary straps are riveted to the upper ends of the uprights, one on each side. 
14 



210 FAULTY ATTITUDE 

The brace is finished by being covered with leather, or by being nickel-plated, 
with leather covering to the front of the brace. The brace is attached to the 
body at the top by means of axillary straps and below by means of a broad belt 
of sheep-skin or cloth, which fits the abdomen and supports the lower part of it. 

Such a brace is worn continuously between exercise periods but 
not during the night. 

Summary of the Treatment of Round Shoulders. — Flexible cases are 
treated by gymnastics like postural scoliosis; a corset- waist or brace 
may be necessary to maintain a correct position between treatments. 

Resistant cases must first be made flexible — (a) by gymnastics; (b) 
by manual stretching; (c) by stretching in apparatus; (d) by forcible 
correction, after which the problem is to maintain the improved posi- 
tion, just as in cases originally flexible. 



INDEX 



Acquired scoliosis, 102 

Age, 114 

Anatomy, 8, 26 

Arthritis deformans, 105-126 

Articular processes, 40 

Attitude, faulty, 191 

normal, 191 
Asymmetrical exercises, 146 
Average heights and weights, table, 72 

Back, surface anatomy of, 26 
Bone, plasticity of, 47 
Bony rotation, 49 
Braces, 151 

Cervicodorsal scoliosis, 66 
Cicatricial scoliosis, 109 
Compound scoliosis, 67 
Congenital scoliosis, 99, 124 
Corrective jackets, 151-157 
Corsets, 151 
Creeping exercises, 150 
Curves, physiological, 11 

Diagnosis of round shoulders, 204 

of scoliosis, 124 
Diseases of the extremities, 106 
Dorsal scoliosis, 63 
Dorsolumbar scoliosis, 65 
Double curves, 50 

Elasticity of the spine, 21 

Empyema, 108, 125 

Etiology of round shoulders, 201 

of scoliosis, 97 
Evolution of the spine, 20 
Examination for scoliosis, 71 
Exercises, asymmetrical, 146 

creeping, 150 

symmetrical, 140 



Flexion of the spine, 30 
Forcible correction, 157 
Frequency of scoliosis, 70, 112, 115 
Functional scoliosis, 53 

Gymnastics, 130, 132 

Habit scoliosis, 109 
Habitual scoliosis, 61 
Heart disease, 109 
History of scoliosis, 1 
Hyperextension of the spine, ^2 
Hysterical scoliosis, 108 

Identification of vertebrae, 26 
Inclination of pelvis, 23 
Infantile paralysis, 106, 125 
Intervertebral discs, 10, 88 
Ischias Scoliotica, 108 

Jackets, removable, 172 

Kyphoscoliosis, 65 

Lateral corrective pressure, points for, 

28 
Lateral flexion of spine, 32 
Ligaments of the spine, 12, 88 . 
Lumbar scoliosis, 62 

Mechanism of scoliosis, 43, 58 
Movements of the spine, 29 

conclusions of, 41 
Muscles of the spine and thorax, 16, 
27, 89 

Nerve supply, 18 
Nervous diseases, 107 
Normal attitude, 191 
examination of, 73 



False scoliosis, 53 
Faulty attitude, 191 
Flat back, 200 



Occupation scoliosis, 109 
Occurrence of round shoulders, 202 
of scoliosis, in 



212 



INDEX 



Operative treatment, 187 
Organs, internal, pathology of, 94 
Organic scoliosis, 61 
Ossification of the spine, 20 
Osteomalacia, 105 

Pain, 51 

Paralytic scoliosis, 124 

Pathology of round shoulders, 203 

of scoliosis, 83 
Pelvic inclination, 23 
Pelvis, asymmetry of, 92, 102 

obliquity of, 102 
Photography in scoliosis, 79 
Physiological curves, 11, 21 
Phthisis, 109 
Planes of the body, 21 
Plaster jackets, corrective, 157 
Plasticity of bone, 47 
Points for lateral corrective pressure, 

28 
Postural scoliosis, 53 
Prognosis of round shoulders, 203 

of scoliosis, 127 

Quadruped scoliosis, in 

Rachitic scoliosis, 104, 124 
Record of scoliosis, 79 
Relation to school life, 117 
Removable jackets, 172 
Retrotorsion, 56 
Reverse rotation, 56 
Rickets, 104-124 
Rotation, bony, 49 
of the spine, 36 
Round back, 197-199 

hollow back, 197-199 
shoulders, 197 
diagnosis, 204 
etiology, 201 
occurrence, 202 
pathology, 203 
prognosis, 203 
treatment, 204 
upper back, 200 

Sacro-iliac articulation, 1 2 
Scoliosis, acquired, 102 
cervicodorsal, 66 



Scoliosis, compound, 67 

congenital, 99, 124 

description, 51 

dorsal, 63 

dorsolumbar, 65 

examination for, 71 

false, 53 

from asymmetries, 102 

from cicatrices, 109 

from empyema, 108, 125 

from heart disease, 109 

from malformations of vertebral 
column, 99 

from malformations of scapula 
and thorax, 101 

functional, 53 

habit, 109 

habitual, 61 

history of, 1 

hysterical, 108 

in quadrupeds, in 

lumbar, 62 

mechanism of, 43, 58 

occupation, 109 

organic, 61 

paralytic, 106 

pathology of, 83 

postural, 53 

prognosis, 127 

rachitic, 104, 124 

record of, 79 

structural, 61-127 

symptoms, 51 

terminology, 52 

total, 53 

transitional, 57 

types of, 48 
School fatigue, 117 

furniture, 118 

life, 117 
Schulthess' measuring apparatus, 82 
Sex, 113 
Short leg, 102 

Shoulder girdle, pathology, 92 
Side bending of the spine, 32 
Spastic paralysis, 107 
Spinal ligaments, 1 2 

movements, 29 

muscles, 16, 27 



INDEX 



213 



Sternum, 14, 02 

Stretching of spine, passive, 154 
Structural scoliosis. 51-127 
Surface anatomy of back, 26 
Symmetrical exercises, 140 
Symptoms of scoliosis, 51 

Terminology, 5: 
Thorax, 13, 90 

anatomy of, 8 

muscles of, 16 

shape and boundaries of, 15 
Torsion, reasons for, 38 
Torticollis, 102 
Total scoliosis, 53-127 
Tracings in scoliosis, 81 
Transitional scoliosis, 57 
Treatment of postural scoliosis, 129 

of round shoulders, 204 

of structural scoliosis, 1 27-131 



Treatment, operative, 187 
True scoliosis, 61 
Tuberculosis of spine, 105-126 
Types of scoliosis, 48 

Unequal hearing, 103 

vision, 104 
Upright position, defects of, 44 

mechanics of, 43 

Varieties of structural scoliosis, 62 
Vertebrae, changes in, 85 

identification of, 26 

pathological affection of, 104 
Vertebral column, anatomy of, 8 

Wolf's law, 47 
Writing position, 119 

X-ray in scoliosis, 77 



LIBRARY OF CONGRESS 



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